It’s the job of the American Academy of Pediatricians (AAP) to recommend age-appropriate care for children. But it abdicated that role in 2018 when it published a policy endorsing what is euphemistically termed “gender affirming care” (GAC). This told doctors to accept a child’s perception of gender because, in a postmodern way, kids “know” their authentic gender.

Pediatricians are not allowed to interrogate a child’s affirmations. Instead, they are supposed to begin “reversible” social transition followed by puberty blockers, followed by cross-sex hormones, followed by “surgical affirmation.”

The evidence base for this is weak. The policy cites a single 2015 study with a biased sample:

“… children who are prepubertal and assert an identity of TGD [transgender diverse] know their gender as clearly and as consistently as their developmentally equivalent peers who identify as cisgender and benefit from the same level of social acceptance.”

This fails to account for children’s interaction within social and familial groups. As Australian psychologist and psychotherapist Dianna Kenny notes, the 2015 study’s recruitment  of children “from [those] already fully inducted into cross-gender identifications” may simply reflect the known influence of group reinforcement in early development of gender constancy and awareness.” The researchers thus ended up “obfuscating a differentiation between social conditioning/social contagion processes such as cross-gender modelling, imitation, and social reinforcement for cross-gender behaviour and innate (cross) gender awareness.”  

Affirmation artificially introduces socially-ratified cross-sex identification so that whether it is a cause or a consequence of social transition remains unclear.  

The AAP board doubled down on its 2018 policy last summer, but it promised a systematic review no later than February 2025. It needs one; we all need one.

A big problem for the AAP is the absence of evidence.  As Dr Kenny writes, “There are currently no acceptable theories of gender identity development in children who assert that they are transgender.” Until now the AAP has relied on lowest-quality evidence such as short-term pre-and post-op surveys and studies lacking control groups; systematic reviews are tasked with pegging actual clinical and quality of life benefits objectively measured according to long-term improvements in such areas as  anxiety, depression, and suicidal ideation.

Puberty as an optional developmental pivot

Surprisingly, the AAP offers no age-specific guidance even about puberty. Dr James Cantor has been highly critical of its sloppy standards. He claims that the AAP misrepresented its own sources, especially in relation to developmental issues and the consequences of a measured, therapeutic approach. He pointed out that -- contrary to the AAP’s labeling of the pubertal stage as “an arbitrary age” -- medicine has always recognized the pivotal importance of puberty. “That follow-up studies of prepubertal transition differ from postpubertal transition is the very meaning of non-arbitrary,” he wrote.  “AAP gave readers exactly the reverse of what was contained in its own sources.” Cantor also ripped the AAP’s characterization of watchful waiting as withholding “critical support.”

GAC is supported by experts such as Diane Ehrensaft, a paediatric gender therapist whose wacky mischaracterization of infant and toddler cognitive capacities potentially represents a breach of professional ethics. Ehrensaft became infamous for her interpretation of a toddler’ dislike of barrettes or unsnapping a onesie as pre-verbal indicators of a cross-sex identity.

What about a medicalized child’s loss of fertility? Ehrensaft says that this is the parents’ problem. As one observer noted: “Slick how she side steps the issue of infertility by pivoting to the parents who she demonizes for desiring genetic grandchildren.” Strangely, for someone specializing in pediatric care, she bypasses developmental appropriateness when asked if a pre-pubertal patient has the cognitive capacity to grasp what it means to sacrifice their fertility in order to be affirmed medically, especially when they may equate sexuality--or pregnancy and giving birth-- with gross physical contact.

You need to stare stark madness in the face and confront it. Watch this: "Diane Ehrensaft who is the Mental Health Director, Child and Adolescent Gender Center Gender at UCSF admit that if a child goes from puberty blockers to cross sex hormones the child will be rendered… pic.twitter.com/6kxSZYYD5i

— Justin Hart (@justin_hart) March 14, 2023

No child can give informed consent for something whose ramifications they cannot understand. These include lifelong medication, becoming infertile and sacrificing sexual function. In many instances a child’s desire to change sex masks same-sex attraction, yet this effort to “trans the gay away” may not be understood until it is too late.

Ehrensaft and her colleagues are so invested in a child’s distress that they throw professional detachment to the winds. She even compares gender-questioning youth with dying cancer patients. It’s a kind of moral panic. However, in the case of gender-questioning kids, there is zero evidence that early medicalization prevents mental illness and early death.

Another problem with the AAP’s policy statement is its conflation of gender identity with sexual orientation. In fact, as Cantor has pointed out, the AAP misapplied research on conversion therapy, a term used to describe efforts to change sexual orientation.  The AAP actually describes the proven approach of “watchful waiting” as conversion therapy. But, says Cantor: “there is no evidence to back the AAP’s stated claim about the existing science on gender identity at all, never mind gender identity of children”.  

Dr Leonard Sax , a practicing family physician who has written several excellent books on raising children, says that it is impossible to determine the sexual orientation of a prepubescent child. Even when they are older, it is difficult: “a troubled teenager who cannot be trusted to get a tattoo is somehow empowered to pick her gender and amputate her breasts.”