On the American Academy of Pediatrics' Faulty Brief to the Supreme Court About Gender-Care Bans
My breakdown of the amicus, or "friend-of-the-court", brief that the AAP and a roster of other medical societies submitted to the high court, which is riddled with flaws and remarkable omissions.
On Wednesday, the Supreme Court will hear oral arguments for a landmark lawsuit that seeks to overturn Tennessee’s ban on pediatric gender-transition treatment. I will be there in person to hear arguments from ACLU and Justice Department attorneys as they seek to convince at least five justices that this ban amounts to sex discrimination violating the 14th Amendment’s Equal Protection Clause. In a long-shot bid, they will also attempt to successfully argue that transgender children are a class warranting specific protection under that amendment.
In recent months, scores of amicus, or “friend-of-the-court,” briefs have been submitted to the Supreme Court, both supporting and opposing overturning Tennessee’s ban. Among the most notable is the brief submitted by the American Academy of Pediatrics, or AAP, which among all traditional U.S. medical societies has been most out front in supporting open access to puberty blockers and cross-sex hormones to treat gender dysphoria in minors. The brief stands out for its shaky reporting of facts and the omission of myriad facts and research that would have undermined its central argument: that these medical interventions are uncontroversial, settled practice, and based on sufficiently robust science.
The brief was co-signed by about 20 major medical organizations all told, including the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists. Notably absent was the American Society of Plastic Surgeons, which recently clarified that it has not endorsed pediatric gender-transition treatment. (So anytime you hear someone, like GLAAD, claim that “all major medical organizations support gender-affirming care for youth,” you know they are making a false claim.)
Here are all those who signed the brief:
Notably, the AAP brief was also signed by the activist-medical organization the World Professional Association for Transgender Health. WPATH publishes the widely referenced Standards of Care guidelines on treating transgender people, including children.
WPATH is the subject of a scathing amicus brief submitted to the Supreme Court by Alabama attorney general Steve Marshall, a Republican, in support of the Tennessee ban. As a part of the separate federal lawsuit over Alabama’s own ban, Mr. Marshall subpoenaed a trove of internal documents from WPATH. Many of them were unsealed in June. The stories they revealed have undermined WPATH’s credibility as a transparent and science-minded organization where pediatric gender medicine is concerned. In particular, these records demonstrated how members of WPATH leadership were well aware that the research behind pediatric gender-transition was weak. They sought to paper this over in the 2022 revision to the Standards of Care—which is known as the SoC 8, given it is the 8th edition.
The AAP Amicus Brief
In the summary of its argument in its amicus brief to Supreme Court, the AAP asserts that the medical treatment that Tennessee has banned is “critical, medically necessary, evidence-based care for gender dysphoria.” The brief pledges to provide an “accurate description of the relevant treatment guidelines and summarize the scientific evidence” behind this treatment. The brief notes that the case against the Tennessee ban, called U.S. v. Skrimetti, only concerns medication-based gender transitions for minors and not surgeries. And in a footnote, the brief characterizes gender-transition surgeries as “typically available to adults”—an apparent suggestion that minors uncommonly receive such surgeries.
Several things:
In the Alabama brief, Mr. Marshall reveals that WPATH leadership, absent actual scientific justification, inserted the term “medically necessary” throughout the SoC 8 for the purpose of helping providers secure insurance coverage and to ward against lawsuits.
As for whether pediatric gender medicine is “evidence-based,” journalist Jennifer Block reported in the BMJ in 2023 that evidence-based medicine experts concluded that because the relevant evidence was, in fact, so weak, the field could not justify brandishing the title “evidence based.”
And as I recently reported in The New York Sun:
Since 2020, a half-dozen systematic literature reviews—the gold standard of scientific evidence—have emerged that have found the research backing pediatric gender-transition treatment wanting and inconclusive.
In response to these review papers, and given the substantial risks of gender-transition treatment, including infertility, the heath authorities in five European nations, including the UK and much of Scandinavia, have recently reclassified pediatric gender-transition treatment as experimental and have sharply restricted access.
But despite pledging to provide a comprehensive account of this research and clinical field, AAP makes no mention in its amicus brief of these review findings and the about-face in Europe. Instead, it portrays these medical interventions for children as widely accepted and uncontroversial among doctors. The brief does not clarify that it is referring narrowly to the U.S. medical field when claiming a lack of controversy or disagreement about pediatric gender medicine. Nor does it acknowledge that there is at least quiet pushback from American doctors. Plus, many other skeptical doctors, as I’ve reported, are too afraid to speak out about their concerns about this field of medicine for fear of career damage.
As for the suggestion that children rarely get gender-transition surgeries, this is patently false, as I’ve previously reported. About 6,000 natal girls received top surgery—typically a double mastectomy—to treat gender dysphoria between 2017 and 2023, according to an analysis by Leor Sapir at the Manhattan Institute.
Even in the Harvard study to which I linked above and that sought to downplay how common pediatric gender-transition surgeries are, a chart demonstrating the rate of surgery (as opposed to the number) indicated that people in their late teens have a surgery rate only about 60% below that of adults:
Falsely claiming this treatment is life saving
The AAP amicus brief asserts that untreated gender dysphoria is associated with host of harms, including suicidality, and then claims that because of this, “the effective treatment of gender dysphoria saves lives.”
However, the only study ever to directly assess whether prescribing gender-transition treatment to gender-distressed youth is associated with a difference in their suicide death rate, which came out of Finland and was published in February, found it was not. I was the only U.S. reporter to publish an article in a major media outlet about this study. (Many from the pediatric gender medicine field have criticized this paper, mind you, claiming it employed too strict of a threshold to determine statistical significance.)
Also, crucially, the Finnish study found that while suicide deaths were elevated in youths who attended gender clinics, these deaths were nevertheless rare. This is in keeping with the findings of a 2022 study about British youth. Together, these papers raise an important point that often gets lost among all the threats that children will kill themselves if they don’t get these drugs: that regardless, it is unlikely they will actually die by suicide.
Importantly, suicide prevention guidelines advise against connecting suicides to a single cause and against sensationalizing suicide death. For a masterclass on how not to communicate about suicide, see how the major LGBTQ nonprofits discussed—and exploited—Nex Benedict’s death in Oklahoma.
Failing to acknowledge the flaws in the AAP’s own policy statement
Next, the amicus brief claims that the “medical community,” including the professional organizations that signed the brief, “widely recognizes that the appropriate protocol for treating gender dysphoria in transgender adolescents is ‘gender-affirming care’.” The footnote (number 5) backing this claim refers to the policy statement on the gender-affirming care method that the AAP published in 2018.
Aside from what I’ve already mentioned about the clear disagreement within the global clinical community about pediatric gender medicine, the amicus brief fails to mention the profound scrutiny and scorn that the AAP’s policy statement has faced.
The core thesis of the AAP’s policy statement is that children can be trusted to know their gender identity even at a very young age and should be allowed essentially to lead the way in their own care. It dispenses with “watchful waiting,” in which caregivers discouraged social transitions until it was clear that gender dysphoria was “consistent, insistent and persistent” into puberty. And it endorses the use of puberty blockers and cross-sex hormones to treat gender dysphoria.
In 2019, Canadian sex researcher James Cantor published a scathing critique and fact check of the AAP policy statement. He revealed that many of the statement’s citations not only did not support its claims about the gender-affirming care method for trans-identified minors, but actually contradicted its arguments.
Even WPATH leadership apparently thinks poorly of the AAP policy statement. As the Alabama amicus brief writes: “One of the co-chairs of SOC-8 complained that ‘[t]he AAP guidelines … have a very weak methodology, written by few friends who think the same.’”
The policy statement was actually written by a single person (and edited by a small committee): Dr. Jason Rafferty, a pediatrician and child psychiatrist at Brown University who at the time he drafted the document was still a medical resident. (I reported for The New York Sun on emails of his that I uncovered through freedom-of-information requests; these documents help shed light on the perspectives and motivations of this widely influential physician.)
The policy statement is the subject of a medical-malpractice lawsuit filed against Dr. Rafferty and his clinical colleagues as well as the AAP itself that I first reported about a year ago.
And in October, 22 Republican attorneys general sent a probing letter to the AAP suggesting that they were preparing to sue the organization over the 2018 policy statement, which they alleged violated consumer protection laws by claiming, falsely they asserted, that puberty blockers are “reversible.”
The AAP has never responded to any of the criticisms of the policy statement. In Aug. 2023, the organization re-affirmed its support of the statement, making no changes. The AAP claimed at the time that it would commission its own systematic literature review of pediatric gender medicine. But there is no evidence that it has actually done so, since the authors of such reviews need to pre-publish their methodology; no one has yet done so on the AAP’s behalf. In its amicus brief, the AAP makes no mention of this failure to take action. Instead it simply states: “In addition, AAP has commissioned a systematic review of the existing research, which is part of its normal procedures to perform such reviews on a periodic basis to maintain up-to-date guidelines.”
Overstating the evidence backing gender-affirmative care
“Empirical evidence,” the AAP amicus brief states, “indicates that gender affirming care, including the prescription of puberty blockers and hormone therapy to carefully evaluated patients who meet diagnostic criteria, can alleviate clinically significant distress and lead to significant improvements in the mental health and overall wellbeing of adolescents with gender dysphoria.”
It is remarkable that the authors of this brief are using causal language to describe what they assert are the benefits of gender-transition treatment for children. No studies of these interventions have been structured to support such a causal link. The AAP brief’s claims to that effect are not thus backed by science.
The footnote for the statement in the screenshot above refers to a two-page 2021 New England Journal of Medicine “perspective” article in which the authors argue against criminalizing gender-affirming care. This particular essay only has five footnotes of its own. (The process in which a footnote refers to other footnotes that do not support the original claim is pejoratively known as “citation laundering.”) Two of these footnotes are from the original Dutch cohort study of gender-dysphoric minors who, starting in the 1990s, were put through gender transition treatment and surgeries. But the profile of those young Dutch people is so wholly different from the typical gender-dysphoric minor presenting at an American gender clinic today, that study’s applicability to contemporary U.S. youth with gender dysphoria is quite suspect. Furthermore, evidence-based medicine experts have deemed that the Dutch study’s methodology was weak and thus its results are unreliable.
Another of the NEJM footnotes refers to the WPATH-commissioned 2021 systematic literature review of gender-transition treatment (one of only two that WPATH allowed to see the light of day; it apparently suppressed many others when it did not like the findings, per the Alabama documents). But that paper didn’t actually differentiate between pediatric and adult treatment. Overall, the review authors stated that any certainty in its conclusions about the apparent benefits of gender-transition treatment “is limited by high risk of bias in study designs, small sample sizes, and confounding with other interventions.” They also stated: “We could not draw any conclusions about death by suicide.”
A fourth footnote in the NEJM essay refers to a CDC report on “experiences of violence victimization, substance use, suicide risk and sexual risk behaviors” in transgender high school students. This report does not focus on how blockers and hormones impact those risks.
The fifth and final footnote refers to 2020 survey study by University of California, San Francisco (UCSF) child psychiatrist Dr. Jack Turban that purported to find an association between having wanted and received puberty blockers during adolescence and subsequent lower suicidality over the years, compared with wanting but not receiving them. But the study is subject to multiple biases, and according to evidence-based medicine experts, it does not provide solid evidence of puberty blockers’ efficacy.
Zeroing in on puberty blockers’ supposed efficacy
In a separate amicus brief to the Supreme Court that Dr. Turban cosigned with other “expert researchers and physicians” in opposition to Tennessee’s ban, the group sought to undermine the authority of Britain’s Cass Review. Published in April after a four-year development period, the review offered a scathing assessment of pediatric gender medicine, finding the field was based on “remarkably weak evidence.” In their brief, Dr. Turban and his colleagues cast particular scorn on the Cass Review and one of the systematic literature review papers out of the University of York on which the review was based; Turban et al criticize them for isolating the impacts of puberty blockers apart from the impacts of cross-sex hormones. “A related, serious error is that the York SRs treat puberty blockers and cross-sex hormones as distinct [and] review them separately,” they write.
Which is curious, since Turban’s own widely cited 2020 paper did just that.
And there is a long history of doing just that in global pediatric gender medicine, dating back to the first-ever published study in the Netherlands.
Researchers at National Health Service (NHS) pediatric gender clinic in London tried to replicate the Dutch researchers’ success with puberty blockers. They failed. The Dutch’s foundational 2011 paper had found: “Behavioral and emotional problems and depressive symptoms decreased, while general functioning improved significantly during puberty suppression.” But the British found a null result: “no changes in psychological function.” They nevertheless wrote this up as if it were a positive finding, but only after they had long sat on the disappointing results.
And Children’s Hospital of Los Angeles’ Dr. Johanna Olson-Kennedy recently told The New York Times that her long-unpublished study of puberty blockers similarly found no associated mental-health benefits. Dr. Olson-Kennedy has since denied under oath that she is withholding publication of these findings for political reasons.
Scientific rigor?
In their opening, authors of the AAP amicus brief assert that the contents of their filing will describe the “scientifically rigorous process by which” trans-care guidelines for minors were developed and will detail the related evidence that backs pediatric gender-transition treatment.
They go on to highlight the WPATH and Endocrine Society guidelines in particular.
And yet, according to the Alabama amicus brief, the process by which WPATH revised its Standards of Care was anything but rigorous. The Cass Review and the York systematic literature review on clinical guidelines were particularly scornful. Cass found what WPATH’s guidelines “lack developmental rigor.”
The chapter of the SoC 8 on caring for adolescents explicitly states that the research base on which the guidelines was based is patchy. And behind the scenes, WPATH leaders privately acknowledged how weak the evidence base was, according to the Alabama brief. They also, under pressure from the Biden administration and the AAP, removed the age limits on gender-transition treatment and surgeries without engaging in their scientific method, known as Delphi, for reaching consensus on making such changes.
The AAP brief, for its part, seeks to degrade the Cass Review. It falsely claims that the review was a systematic review (not mentioning that the Cass Review was based in part on 7 systematic literature reviews from the University of York). It then mischaracterizes what a systematic review while dismissing such academic efforts: “However, the Cass Review, like other systematic reviews, is simply a summary of some of the existing research, as selected by the author.” The brief leaves out the part in which all the systematic reviews that have examined pediatric gender-transition treatment have assessed the quality of the research and the corresponding degree to which one can have confidence that its findings are valid.
This dismissal of the importance of systematic literature reviews evokes what Dr. Turban dismissively said about them in a deposition he provided as an expert witness contributing to a legal challenge to Idaho’s Vulnerable Child Protection Act. As Dr. Sapir of the Manhattan Institute reported:
In the deposition, [John Ramer, an attorney with the law firm Cooper & Kirk] asked Turban to explain what systematic reviews are. “[A]ll a systematic review means,” Turban responded, “is that the authors of the reports pre-defined the search terms they used when conducting literature reviews in various databases.” The “primary advantage” of a systematic review, he emphasized, is to function as a sort of reading list for experts in a clinician field. “Generally, if you are in a specific field where you know most of the research papers, the thing that’s most interesting about systematic review is if it identifies a paper that you didn’t already know about.” Ramer showed Turban the EBM pyramid of evidence, which appears in the Cass Review (page 62) of the U.K.’s Gender Identity Development Service. He asked Turban why systematic reviews sit at the top of the pyramid. Turban responded: “Because you’re looking at all of the studies instead of looking at just one.”
How many kids does this medical field impact?
The AAP amicus brief vastly under-reports the number of adolescents believed to identify as transgender in the United States. The authors cite the Williams Institute at UCLA Law School when stating that between 2017 and 2020 about 10% of the 1.6 million transgender people in the U.S., or 160,000, were 13 to 17 years old. This is incorrect. The report they cite estimates that there were, in fact, 300,000 trans Americans in this age range:
The AAP amicus brief authors make no mention of the chance—or likelihood—that young people might desist, or revert to identifying as their natal sex, absent gender-transition treatment. (Research on this question is controversial, but traditionally shows that prepubescent kids with gender dysphoria in particular tend to desist.) Instead, the brief focuses exclusively on the potential harms of not providing such a medical intervention, including “depression, anxiety, self-harm and suicidality.”
“In contrast,” they write, “with treatment, transgender adolescents with gender dysphoria can mature into thriving adults.”
And yet there is very little follow-up research on people who have received such treatment as minors to back such a bold claim. How these young people turn out in life remains a big black box. We might have had the benefit of some clarity on what became of the thousands of British children who underwent this treatment over the past dozen years. But the adult NHS gender clinics refused to share data on those former pediatric patients with the Cass Review team.
Dr. Riittakerttu Kaltiala, the child psychiatrist who established one of Finland’s two pediatric gender clinics, in 2011, found through her clinical experience and her research that in general, providing cross-sex hormones to youth did not alter these patients’ well-being. In short, she found that those who were already doing well kept doing so, and those who were faring poorly did not improve. I saw her give a presentation to this effect at the Society of Evidence Based Gender Medicine (SEGM) conference in New York in October 2023. (The Southern Poverty Law Center claims that SEGM is a hate group. I have seen no evidence to back this claim, the lengthy SPLC report to that effect notwithstanding.) I heard Dr. Kaltiala describe how many of these young people had a complete failure to launch, including a lack of a romantic partner or job, no attendance at school, and an inability to even go outside of their parent’s home.
How well accepted are these medical practices?
The claim in the AAP brief that gender-affirming care for minors is “widely accepted” is based on something of a mirage. Small committees within medical societies are generally responsible for any statements of official support for these medical interventions, or statements of opposition to state bans.
The AAP, for one, has never surveyed its members about its gender-affirming care policy statement, despite years of pressure from Oregon pediatrician and AAP dissident Julia Mason to get them to do so. So it remains largely unknown what rank-and-file AAP members actually typically think of these practices.
What is clear is that pediatric gender medicine has firmly established itself within major medical centers across the nation—or at least it had done so until the bans against such treatment were passed in 24 states between 2021 and 2023. The Supreme Court will determine whether such bans are constitutional. A decision on the matter is expected in June.
Are the assessments actually thorough?
The question of whether the WPATH-recommended assessments that minors are at least meant to receive from mental health professionals before receiving approval to undergo a medicalized gender transition are, in fact, “thorough,” as the AAP amicus brief asserts, remains wildly controversial.
But we’re starting to get more clarity on the matter.
Last month, I reported for The New York Sun about the practices at Boston Children’s Hospital, which was the first hospital to establish a pediatric gender clinic in the U.S., importing the treatment model from the Dutch researchers in 2007. My reporting revealed that it has been the policy at Boston Children’s gender clinic since 2018 to provide gender-dysphoric kids and their parents only a single two-hour assessment appointment. It took a civil trial for this information to finally come to light.
Reuters conducted an investigation in 2022 that found that at 7 of the 18 pediatric gender clinics they surveyed, the staff would provide gender-transition drugs to minors after a single appointment if they “didn’t see any red flags.”
In his recent book on trans kids, Dr. Turban repeatedly strongly suggests that he thinks these assessments are worthless and should be done away with.
Regarding whether WPATH’s pediatric gender-care guidelines are “evidence based” as the amicus brief claims:
The brief neglects to mention that every single person on the WPATH guidelines committee had a professional conflict of interest: They all worked in the trans-care field and had a vested interest in promoting it. Evidence-based medicine experts advise having more of a balance on guidelines committees by including people who do not stand to gain professionally and financially from the outcome of the endeavor.
The AAP amicus brief stresses how individualized the psychosocial assessments are. Although one wonders how tailor-made such an assessment can be if it only lasts two hours. In my reporting on Boston Children’s, I found that two former psychologists from its gender clinic said it was simply impossible to conduct a proper assessment in so little time.
In a recent paper that Dr. Turban published with his senior colleague, UCSF psychologist Diane Ehrensaft, about how to conduct an assessment of a gender-dysphoric child, they insisted that the purpose of these assessments is not to determine whether a child “is really transgender.” (Dr. Turban also did not acknowledge that he was contradicting his own book, which denigrated these assessments.)
It is remarkable that such mental health professionals neither have at their disposal, nor are seeking to develop, a system that could help predict whether an adolescent’s gender dysphoria is likely to be permanent. Pediatric gender medicine experts insist that if such dysphoria persists into adolescence, it is very unlikely to dissipate.
And yet two recent analyses of medical records data, one in the U.S. and the other in Germany, found that the majority of youths with a gender-dysphoria-like diagnosis entered into their chart saw it disappear within six years, as I reported for The New York Sun.
How many kids should get blockers, and what are they for?
The AAP brief is careful to emphasize that “gender-affirming medical care may be indicated” only for “some” trans youth. This stands in conflict with a statement that WPATH issued in April in which the organization asserted that the majority of gender-distressed youth would do best to follow a medicalized transition.
The “time to think” fallacy is alive and well in the amicus brief, which asserts that the purpose of puberty blockers is to delay puberty “until adolescents are old enough and have had sufficient time to make more informed decisions about whether to pursue further treatments.”
It is now widely recognized in this field that nearly all children who start blockers for gender dysphoria eventually start taking hormones. Critics have suggested that this indicates that children do not see the time on blockers as a period meant for self-reflection. Instead, these kids seem to see the time on blockers as a way station until they get what they actually want: hormones.
Supporters of open access to such treatment have claimed, by contrast, that the very high rate of continuation means that the assessments identified the right candidates with near-perfect accuracy. In her book about the collapse of the NHS’s pediatric gender clinic, Time to Think, the title of which is meant to be ironic, British journalist Hannah Barnes highlights how it is quite unheard of in psychology to have a perfectly or near-perfectly accurate assessment mechanism.
There’s considerable confidence about the safety of puberty blockers in the amicus brief, which states that these drugs have “well-known efficacy and side-effect profiles” and that “serious adverse effects” from them “are exceedingly rare.”
This stands in contrast to a Feb. 2024 review paper published by University College London neuropsychologist Sallie Baxendale, which sought to examine what the available research can—and cannot—tell us about the neuropsychiatric impacts of puberty blockers.
Dr. Baxendale concluded:
Critical questions remain unanswered regarding the nature, extent and permanence of any arrested development of cognitive function associated with puberty blockers. The impact of puberal suppression on measures of neuropsychological function is an urgent research priority.
This brings us about halfway through the AAP amicus brief. In the interest of time, I’m going to stop here. I’ll do my best to finish my appraisal of this document by Monday or Tuesday. Stay tuned for Part II…
Follow me for my reporting about the Supreme Court hearing on Wednesday.
I am an independent journalist, specializing in science and health care coverage. I contribute to The New York Times, The Guardian, NBC Newsand The New York Sun. I have also written for the Washington Post, The Atlantic and The Nation. Follow me on Twitter: @benryanwriter and Bluesky: @benryanwriter.bsky.social. Visit my website: benryan.net
Benjamin, thank you so much for this comprehensive reporting. I am so grateful for resources like these that I can send to my MLA (a member of the opposition) in the hopes that this can stop being a partisan issue here in Alberta and we can all agree on some basic facts and premises. The thinking in progressive circles is so misguided, it’s very disheartening. I appreciate that you persist in presenting facts and reason.
Thank you Ben! I hope to meet you on Wednesday 😉