Major Medical Associations Support Gender Affirming Care. So What?

Clinician advocacy groups are not neutral

Photo by Volodymyr Hryshchenko on Unsplash

“Every major medical association in the US supports gender affirming care for trans youth,” GLAAD likes to remind us.

To the uninitiated, that list of supporters looks impressive: the American Medical Association, the American Psychological Association, the American Academy of Pediatrics, among many others. Healthcare consumers might naturally assume that these groups rest their endorsements on evidence—and that, because they support the gender-affirming approach, it’s the best one.

But these medical associations are advocacy groups. They represent the interests of clinicians, not patients. Their job is to protect—and sometimes lobby for—doctors and psychologists. They are not neutral, nor are they above reproach.

A 2012 article from the Public Citizen, “The American Medical Association and Its Dubious Revenue Streams,” notes that “The AMA’s power stems from both its political clout on Capitol Hill and its symbiotic, money-tinged relationship with the larger sectors of the health care system, such as the hospital, insurance, and pharmaceutical/medical device industries.” Here’s a nifty list of scandals and cover-ups, in which the AMA was primarily concerned with silencing critics or ventures that would siphon off market share, like alternative medicine. In the 1994 book The Assault on Medical Freedom, Sourcewatch notes, “the AMA is characterized as a greed motivated trade union, eliminating competitors to its own financial and political interests.”

But, yes, the AMA supports gender-affirming care. The question is: should its endorsement reassure you—or make you suspicious of that care?

I’m willing to concede that some doctors in the AMA believe this is the right approach. But perhaps the AMA as an organization supports the paradigm not just because they believe in it but because the alternative—psychological support—earns its constituents zero dollars. Formerly, the preferred approach to treating gender dysphoria in youth was watchful waiting. Under that treatment paradigm, gender dysphoric children weren’t socially transitioned, and they received counseling and assessment over many years. On average, about 80 percent of those kids were no longer gender-dysphoric by the end of puberty. Thus, no business for endocrinologists or surgeons. As with vegetarian diets and naturopathic medicine—which the AMA has apparently come out against at times—watchful waiting is a healthcare approach that reduces the likelihood of profitable medical interventions.

But when children are socially transitioned, it seems they are both much more likely to persist in a trans identity, and much more likely to medicate. And social transition is an important part of the affirmative process. Perhaps that’s part of why medical associations endorse it?

Most of those medical associations—that is, advocacy groups—are following the lead of the American Academy of Pediatrics (funded by multiple pharmaceutical companies), which released a policy statement in 2018, “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents.” The statement promotes the gender-affirmative care model, and blames minority stress for cooccuring psychological issues. “[I]f a mental health issue exists,” the statement reads, “it most often stems from stigma and negative experiences rather than being intrinsic to the child.” It notes that “All clinical office staff have a role in affirming a patient’s gender identity,” and goes on to make claims about the risks of suicide and the effects of puberty blockers and hormones, conflating anything but affirmation with conversion therapy.

After the statement was published, psychologist and sexologist James Cantor fact-checked it. He wrote:

Although almost all clinics and professional associations in the world use what's called the watchful waiting approach to helping gender diverse (GD) children, the AAP statement instead rejected that consensus, endorsing gender affirmation as the only acceptable approach. Remarkably, not only did the AAP statement fail to include any of the actual outcomes literature on such cases, but it also misrepresented the contents of its citations, which repeatedly said the very opposite of what AAP attributed to them.

But, yes, the AAP supports gender-affirming care—by virtue of twisting data and ignoring dissent.

Notably, the AAP has gathered evidence of the efficacy of transition, but has refused to do a systematic evidence review, which evaluates the quality of that evidence. That is, you can find studies that say hormones improve depression, but if they are of very low quality, it means: “We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.”

Well, guess what? Non-partisan, governmental healthcare organizations in Sweden, Finland and the UK did conduct systematic evidence reviews, and they found the evidence to be of low and very-low quality.

These countries all saw the same massive changes that we’ve seen here:

• exponential increases in young people diagnosed, or self-diagnosing, with gender dysphoria;

• a heretofore unseen population of teen girls with other mental health concerns and sudden trans identities;

• an increase in the number of detransitioners, who regretted transitioning;

• and an evidence base that didn’t support affirmation.

Many clinicians in these countries were alarmed by this, and blew the whistle or asked for governmental oversight—rather than denying it, covering it up or explaining it away, as medical associations and some of the clinicians they represent do here.

These countries have governmental bodies that conduct systematic evidence reviews and create non-political guidelines. They have socialized medicine, which means they collect better data and have little financial incentive to offer interventions that either may not work or might actively hurt people. So they stopped the affirmative model, opting for long-term, careful evaluation with multidisciplinary teams, and approve medical transition rarely, and with mandated long-term follow-up, often only within clinical trials.

The Swedish National Board of Health and Welfare, for instance, notes “that the risks of puberty suppressing treatment with GnRH-analogues and gender-affirming hormonal treatment currently outweigh the possible benefits, and that the treatments should be offered only in exceptional cases.” In England, pediatrician Hilary Cass evaluated—and then shut down—the Gender Identity Development Service, to replace it with regional centers that will lead with psychological support.

Lots of American medical associations support gender-affirming care. But in countries with healthcare systems that collect and respond to data, rather than politicizing it, and where guideline-writers have listened to those who’ve gotten hurt, medical associations do not. The fact that American medical associations support the gender-affirmative model is a sign of how broken our healthcare system is.