The AAP Needs to Listen to Parents
We don't just need a systematic evidence review—we need to listen to parent voices.
When Melissa’s 17-year-old son was hospitalized for anorexia at a well-respected residential facility for kids with eating disorders, she was sure they would help make him well.
The next day, Melissa (not her real name) received a call from the therapist making the rounds on the ward—not about her son, but about her daughter. “Your child is transgender,” the therapist said. “She needs to start hormones right away.”
Melissa was flabbergasted. Her son had not only never come out to her, but he’d shown no signs of gender nonconformity throughout his childhood, other than recently having long hair. Nor had he exhibited a single sign of gender dysphoria—distress at a perceived mismatch between your body and your sense of self as boy, girl, or neither. He was bright but socially awkward, quirky, and desperate to be liked by his peers, who often shunned him. She suspected he was on the spectrum. But Melissa had hardly found a moment to shepherd him through the trials of puberty, because her entire life had been dedicated to helping his sickly older sister.
Melissa wanted him to stabilize first, to get the anorexia under control and deal with their underlying family trauma. Then they could investigate the gender issues. But the therapist, who had talked to her son for less than an hour, insisted it was the other way around.
“They said gender dysphoria can cause the eating disorder, so if he does not transition right away, he will not get better,” Melissa told me. No one discussed, with Melissa or her son, any possible health complications from cross-sex hormones, that he might be sterilized or a life-long medical patient if he started them. Another psychiatrist told her, in front of her son, that if she didn’t affirm and transition him, he would kill himself. When she said she needed more time, a staff member later told her, the team discussed calling child protective services, suspecting she was transphobic.
There is nothing unusual about Melissa’s story. In my interviews with parents of trans-identified kids, and sometimes with their detransitioned or desisted children, I have heard countless similar tales. Parents have been blindsided by their kids’ internet-influenced announcements; duped by school personnel who hide information about the kids’ mental health; lied to by medical and mental health professionals about suicide risks; bullied and pressured by affirming clinicians to disregard their own knowledge and judgement about both their children’s histories and their futures.
In short, the parents have been treated like criminals and enemies by the adults and the activists, who have taught their children to view them that way, too.
Like so many other parents, Melissa tried—for years—to get her son help that was based on evidence, not ideology, but the practitioners were routinely influenced by the American Academy of Pediatrics’ 2018 policy statement, “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents.” It states that “children who are prepubertal and assert an identity of [transgender/gender diverse] know their gender;” calls the traditional watchful waiting approach “outdated;” and conflates that method with conversion therapy. Despite the document admitting that it’s “not a comprehensive review of clinical approaches,” and that “gender affirmation” was “formerly referred to as ‘transitioning,’” some believe that it’s the most influential policy in the battle over how to treat kids with gender dysphoria, or who identify as trans. It’s what judges, and those who judge in the court of public opinion, defer to.
So it’s great news that the AAP has finally agreed to conduct a systematic evidence review, thanks to the bravery of a few dogged and determined pediatricians like Dr. Julia Mason.
It’s weird news, though, that in the meantime they’re sticking by their 2018 policy statement, despite the fact that Dr. James Cantor fact-checked it and found that “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.”
A systematic evidence review prevents the cherry-picking of studies and evaluates not just the outcomes but the quality of the studies. (Here’s a good primer by the pro-evidence group SEGM.) All previous systematic evidence reviews, from countries like Sweden and England, have found the research to be of low or very quality, so it will be astounding if the AAP reviews manages to reach a different conclusion, considering they’re all working with the same small set of studies.
Should they admit to the low-quality evidence—which means actual outcomes may differ wildly from whatever happened in the study—they may explain it away with “plenty of other procedures have low-quality evidence.” But some of those procedures may not be particularly serious or invasive; gall bladder surgery and adolescent “sex” changes are not the same level of risk.
Regardless of what happens, anyone looking at evidence, at research, at outcomes for kids with gender dysphoria and/or who transition should be listening to the voices of parents. There should be a parents’ commission that reports to the medical associations—which, remember, are advocacy groups for clinicians, not for patients—and to various lawmakers trying to create law and policy around gender and kids.
Rather than dismiss them as out of touch or bigoted, we should assume, until we know otherwise, that these parents love their children and want what’s best for them, that they know their children and have insight into their lives. In addition to conducting a systematic evidence review, the AAP should invite parents of trans-identified kids to share their stories of the affirmative model of care—and listen to them. (There are hundreds of them already collected on the PITT Substack, and in their forthcoming book; perhaps someone should mail them to AAP members.)
No movement should try to drive wedges between families, as there is no evidence anywhere that says that children who are estranged from their parents and transition do better than those who stay connected, even if there is disagreement about identities or medication. Any clinician who is responsible and compassionate includes parents in their children’s treatment plans, and doesn’t triangulate, pressure, or estrange.
(PS: This is not my idea. It came from a quick reply to last week’s roundup, written by a very experienced clinician. Thanks for the inspiration.)
I have no faith that the AAP will do an honest review process. When asked about the reviews that in Europe, their response (after doubling down on their 2018 position and saying they feel confident it’s correct) was: “They gave their process, we have our process.”
The way the AAP (and the APA for that matter) has completely cut out the family and encouraged lying, secret keeping, and triangulation should be major red flags to anyone who knows anything about child and adolescent development. Even if not affirming was abuse (I’m not saying it is, I’m making a point), the goal of social workers, pediatricians, and CPS has always been to do everything possible to support and preserve the family and not rupture it except in the most extreme cases. Yet on this one issue, the policy is to triangulate and go straight to rupture. This is extraordinary, and to paraphrase, extraordinary policies require extraordinary evidence.
Our now desisted minor daughter was routinely told by professionals to go no contact with us the moment she turned 18. They never once considered what that would realistically look like for her and they certainly weren’t going to be there to offer her financial or emotional support or even follow up to see what happened when she was suddenly alone with no high school diploma, no housing, no job, no family, and untreated depression and anxiety because they never treated that - they only talked about her gender identity.
One other point about how parents are cut out: This also happens in the online autism/neurodiversity activism movement, which of course has huge overlap with LGBTQIA+ activism because of the high rates of autism in the recent adolescent spike in gender dysphoria. Parents with any concerns or who try to offer any perspective for their autistic child are routinely told to sit down and shut up. It is vicious.
I am a recently retired pediatric specialist. I was a member of the AAP with my membership fees paid by my academic pediatric department, likely a deal to increase the membership numbers artificially. I too have little faith in this organization. The literature is clearly inadequate to support the kind of position that the AAP, AMA, and Endocrine Society have taken. The procedures of transgender clinics in children's hospitals have employed include highly biased coaches who only encourage transition to another gender is appalling and unethical. The issue of informed consent and the impossibility of assent have rarely been addressed.