Expert Critics Of The HHS Report On Youth Gender Medicine Are Projecting—And Helping Implode Their Own Credibility (Part 1 of 2)

An ongoing theme, unfortunately.

Last month, as I reported in The Dispatch, Donald Trump’s Department of Health and Human Services released a comprehensive review of the evidence for youth gender medicine practices. (For those who can’t get through The Dispatch’s paywall, I’ll include my full article below this one, for paying subscribers to this newsletter.)

I don’t blame people for reflexively distrusting this document. There are plenty of valid reasons to do so.

First, the review was commissioned by a president who doesn’t value science and who is seeking to massively scale back U.S. investment in it. HHS is run by Robert F. Kennedy Jr., who has embraced and disseminated many pseudoscientific theories, including dangerous ones like the idea of a link between childhood vaccines and autism. More recently, RFK Jr. led a “Make America Healthy Again” commission on childhood health that just published a truly embarrassing report that contained countless miscitations, including, in some cases, AI-generated citations to nonexistent papers.

In addition, the executive order that birthed the HHS review on youth gender medicine was not written in a compassionate, open-minded way — it was titled “Protecting Children from Chemical and Surgical Mutilation” and its content seemed to clearly indicate the administration had already made up its mind, even as it called for an evidence review.

Finally, the administration has not so far released the names of the authors of this report, who are external to HHS. I agreed to keep those names off the record in exchange for early access to the document, which was less than ideal but which allowed me to break the news of its publication. HHS claims that it is withholding the names of the authors because there are peer-review processes underway for some of the chapters, as well as some sort of opportunity for critics to respond, the implication being that if the names came out, it would complicate these efforts. But if, say, a couple months from now, these names still aren’t public knowledge, I think that will be a major problem, and I’ll be happy to press that point.

Anyway: As I wrote in my Dispatch article, despite the reasons to be skeptical of the HHS report, it’s actually well done: It solidly sums up the present state of the controversy and the lack of evidence for youth gender medicine treatments. Perhaps this is proof that the Bureaucracy Gods have a sense of humor. Someone in HHS happened to choose a professionally minded lead for this project. That lead, in turn, built a team of smart, thoughtful critics of youth gender medicine.

Again: I don’t blame anyone for not believing this. But that’s what happened.

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This piece isn’t about the HHS report, though — it’s about how authoritative mainstream institutions reacted to it. Rather than respond to the actual words of the actual document, they have misrepresented, deflected and, in most cases, refused to answer any follow-up questions. This is a jarring case study in how experts have mortgaged their authority, leaving the average person simply trying to understand this issue better — not to mention parents and young people considering these treatments — in a very difficult situation.

Of particular note is the extent to which some critics of the HHS report seem to be projecting: They have done exactly what they are (falsely) accusing the authors of the report of doing. This is a pattern, and in the long run, when the dust settles from the American youth gender medicine dispute, these institutions are going to have a lot of trouble regaining the credibility they have rather publicly mortgaged.

In this critique, which I’m splitting into two parts for our collective sanity, I’m going to focus on the American Academy of Pediatrics, the leading youth gender researcher and advocate Kellan Baker, and Science magazine. This is going to be long, because there is a lot of context and background here that can’t really be left out if I’m going to mount a convincing argument about the irresponsibility that has been on display since the HHS report came out.

The American Academy of Pediatrics and Its Speed-Readers

The HHS report is more than 400 pages long (there’s also a lengthy appendix). It was first made available at 6:00 a.m. Eastern on May 1. By 12:30 p.m. that day, at the latest, the AAP had published a statement denouncing it.

Here is that statement in its entirety:

AAP Statement on HHS Report Treatment for Pediatric Gender Dysphoria

By: Susan J. Kressly, MD, FAAP, president, American Academy of Pediatrics

“The American Academy of Pediatrics (AAP) is deeply alarmed by the report released by the U.S. Department of Health and Human Services (HHS) today on medical care for transgender and gender-diverse individuals and the process that informed its development. For such an analysis to carry credibility, it must consider the totality of available data and the full spectrum of clinical outcomes rather than relying on select perspectives and a narrow set of data.

This report misrepresents the current medical consensus and fails to reflect the realities of pediatric care.

As we have seen with immunizations, bypassing medical expertise and scientific evidence has real consequences for the health of America’s children. AAP was not consulted in the development of this report, yet our policy and intentions behind our recommendations were cited throughout in inaccurate and misleading ways. The report prioritizes opinions over dispassionate reviews of evidence.

Patients, their families, and their physicians—not politicians or government officials—should be the ones to make decisions together about what care is best for them based on evidence-based, age-appropriate care.

We urge government officials and policymakers to approach these conversations with care, humility, and a commitment to considering the full breadth of peer-reviewed research. The AAP remains focused on supporting pediatricians in delivering the best possible care to every child, informed by science and the lived experiences of patients and families. We will continue to support the well-being of all children and access to high-quality care that meets their needs.”

These are serious claims. But there are zero details explaining how the HHS authors failed to “consider the totality of available data and the full spectrum of clinical outcomes,” in what sense the report “rel[ies] on select perspectives and a narrow set of data,” or how the report “misrepresents the current medical consensus and fails to reflect the realities of pediatric care.” That first claim, in particular, would be tough to support, given that the inclusion, in the HHS document, of an umbrella review of all the existing systematic reviews, is pretty close to the definition of “consider[ing] the totality of available data[.]”

I emailed the listed press contact to try to set up an interview with Susan J. Kressly, but was told the AAP wouldn’t be answering further questions about the statement. It should, because in addition to the lack of evidence, anyone familiar with the recent history of the AAP will see that it is accusing the HHS team of doing exactly what it has done in recent years.

In 2018, the AAP published a “policy statement” lead-authored by the psychiatrist and youth gender clinician Jason Rafferty that suffers from basically every flaw the organization attributes to the HHS report, and which is still considered to be the AAP’s active guidance on the subject of youth gender medicine.

“The Rafferty statement,” as it is commonly known, is larded with activist language, strange claims, and basic errors. For example, it severely misrepresents the “Dutch protocol,” also known as “watchful waiting,” watchful waiting, a key part of the so-called “Dutch Protocol” that is the progenitor of the “affirming” approach common in the U.S. and explicitly supported by the AAP. “This outdated approach does not serve the child because critical support is withheld,” the statement argues. “Watchful waiting is based on binary notions of gender in which gender diversity and fluidity is pathologized; in watchful waiting, it is also assumed that notions of gender identity become fixed at a certain age.” This is a profound misrepresentation of that part of the Dutch protocol.¹ That’s just one of many examples. James Cantor wrote the most important fact-check of the Rafferty statement, published here in the Journal of Sex and Marital Therapy.

In a sign of seriously low quality standards, the Rafferty statement is shot-through with citational misrepresentation — that is, instances in which citations don’t come close to supporting the claims to which they are affixed. Kathleen McDeavitt’s letter to the editor published in the Archives of Sexual Behavior sums this up nicely:

The AAP Policy Statement, which was recently reaffirmed in 2023, contained a short narrative review of the evidence for mental health outcomes to support its recommendation for [puberty blocker and hormone] use in certain [transgender and gender diverse] adolescents. Out of the seven citations provided in this narrative review, only one was actually a clinical outcomes research study that found improvement in mental health outcomes. In that study, clinical significance of improvement was unclear. [citations omitted]

These are extremely basic citation errors. In a couple of instances, for example, Rafferty et al. support their claims of youth gender medicine’s efficacy in boosting mental health by citing papers that merely described the protocols in use at a couple of treatment centers but that “did not report any mental health outcome data,” as McDeavitt puts it.

Just to show you how severely Rafferty and his colleagues misrepresented the extant literature, let’s briefly review one sentence and its three citations: “There is a limited but growing body of evidence that suggests that using an integrated affirmative model results in young people having fewer mental health concerns whether they ultimately identify as transgender. 24, 36, 37”

To make even this modest claim about the evidence base for “an integrated affirmative model,” Rafferty and his team are forced to reach for citations that are simply inapplicable.

Footnote 24 points to this 2012 paper published by Laura Edwards-Leeper and Norman Spack, two of the three clinicians who founded Boston Children’s Hospital’s youth gender clinic, its Gender Multispecialty Service (GeMS). As I know from my extensive conversations with Edwards-Leeper, who at the genesis of the clinic was its sole psychologist, she and her team drew heavily from the Dutch approach — the one the Rafferty statement is decrying as harmfully out of date. Edwards-Leeper explained in a text message that while they referred to their approach as “affirming,” “we had a different definition of affirming.” “Exploration and thorough assessment were a non-negotiable part of the GeMS ‘affirming’ protocol,” she explained. (All the way back in 2016, Edwards-Leeper coauthored an important paper on how ‘affirming’ care meant different things to different providers.) On top of that, this paper presents no outcome data, so it (obviously) cannot be used as evidence for or against the AAP’s preferred flavor of the affirming approach, the Dutch approach, or any other protocol.

Footnote 36 points to this study, “A comprehensive program for children with gender variant behaviors and gender identity disorders,” written by the psychiatrist Edgardo Menvielle and also published in 2012. It’s a short, interesting read about Menvielle’s own experiences helping to lead an early youth gender clinic at Children’s National Medical Center. It includes this passage: “At this time, we lack the guidance of evidence regarding the potential long-term advantages and disadvantages of prepubertal gender-role transition (Dreger, 2009; Zucker & Cohen-Kettenis, 2008). Given that many, if not most, children who express childhood gender variance do not progress or persist into a transgender adult identity, a recommendation for social transition at this stage is given cautiously.” Whatever Menvielle’s current thoughts on the matter, this paper obviously does not promote the affirmative model supported by the AAP, which staunchly rejects the so-called “desistance” literature (sure enough, Rafferty and his colleagues describe that research — falsely — as suffering from serious threats to its validity due to methodological shortcomings). And, at the risk of repeating myself, since the paper seeks solely to relay some of Menvielle’s experiences and recommendations, and to describe his program’s approach, it cannot provide any meaningful information supporting Rafferty et al’s claim, anyway.

Footnote 37 points to another paper on which Menvielle is an author, this one published in 2010. This time it’s a team effort that does involve data, and as he and his team explain in the study’s abstract:

All parents completed the Child Behavior Checklist, the Gender Identity Questionnaire, and the Genderism and Transphobia Scale, as well as telephone interviews. The parents reported comparatively low levels of genderism and transphobia. When compared to children at other gender identity clinics in Canada and The Netherlands, parents rated their children’s gender variance as no less extreme, but their children were overall less pathological. Indeed, none of the measures in this study could predict parents’ ratings of their child’s pathology.

The authors mention the possibility that this could be evidence that their approach is salutary, but caution against overinterpretation given all of the other potential explanations, noting that the paper constitutes “an exploratory ‘post-test only’ study with limited comparisons among a convenience sample of parents. Moreover, this study did not control for exposure or involvement with the program so it is difficult to definitively attribute any effects of the program.” So the authors themselves don’t think this study proves much of anything, when it comes to their approach versus other clinics’.

So here we have a situation in which the leading pediatric organization in the country is claiming that there is “a limited but growing body of evidence” to support one particular protocol, and then citing two publications that can’t buttress this claim (because they include no data), and a third that, while offering some data, really isn’t up to this sort of task.

As McDeavitt notes, in 2023 the AAP reaffirmed its statement. But at the same time, it also announced it would be conducting systematic reviews of the evidence for them. It’s unclear how a professional medical organization could both endorse a treatment as strongly as the Rafferty statement does while simultaneously acknowledging that there’s sufficient doubt about it to warrant a (presumably) expensive, time-consuming systematic review. And as the Society for Evidence-Based Gender Medicine noted:

[W]e find several statements in the AAP press release concerning. One such statement is the assertion that “policy authors and AAP leadership are confident the principles presented in the original policy, Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents, remain in the best interest of children.” Not only is it inappropriate to start a research process with a pre-ordained conclusion, but this conclusion also contradicts the findings of the current systematic reviews of evidence.

Hmmm, starting a research process with a pre-ordained conclusion… sounds familiar, no?

By the way, McDeavitt notes in her letter that no such systematic review has been registered in the International Prospective Register of Systematic Reviews, PROSPERO, which would usually be an early step in this process. I reached out to the AAP to ask about the status of the systematic review, and if they respond I will add an update here. (She also notes, accurately, that at this point enough systematic reviews have been conducted that the AAP should probably just build new guidelines around those rather than conduct yet another. SEGM makes the same point in the above-linked-to-statement.)

The problems with the Rafferty statement neatly capture exactly why expert authority is so important, and what can happen when it is squandered. One major purpose and benefit of having organizations like the AAP is that, ideally, that they can provide shortcuts for members of the public trying to navigate a complicated world. The vast majority of people lack the time and expertise to determine, on their own, the most accurate view on a subject as fraught as youth gender medicine. But expert organizations can, at their best, provide us with accurate guides to what’s going on.

In this case, the AAP’s Rafferty statement couldn’t even meet the extremely low bar of having its citations actually support the claims in question. And it isn’t just Rafferty — 18 other pediatricians put their names on it! This is a breach of trust. This is an organization projecting authority without earning it, an organization claiming that the HHS team failed to “consider the totality of available data,” when that’s exactly what they do in their active guidance on this subject.

So the Rafferty statement is a mess, and for those of us who follow this issue closely, it was a signal that the organization couldn’t really be trusted on this issue. And as I argued recently, the problem isn’t just what gets published, but how journals and other institutions respond when errors in these publications are pointed out to them. All too often, they simply don’t fix what needs fixing.

That’s what happened here: Not only did the AAP allow the Rafferty statement to be published in its present form, with all those citation errors — they explicitly chose to “reaffirm” it without correcting these errors. On top of that, Rafferty and his organization have has been sued by at least two detransitioners who claim they received rushed, sloppy care from him — care that they one blamed in part on his guidelines. One of those two cases has been settled dismissed because the plaintiff declined to pursue it further, while the other — a really terrible one involving a traumatized young woman who had about nine “alter” personalities at the time she sought treatment — is ongoing. (Correction: One of the two cases was settled, not dismissed, and I updated the language to note that the AAP was a defendant in one case, not both.)

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If the 2018 Rafferty statement and its “reaffirmation” left any remaining doubts as to whether the AAP was fulfilling its role as a trustworthy pediatric organization, it was dispelled — or so I would argue — by the Cass Review. Cass, you may recall, commissioned a series of systematic reviews by the University of York on various questions pertaining to youth gender medicine. One of those systematic reviews examined the existing published guidelines, and that review scored the Rafferty document quite poorly. (See Online Supplemental Table 3 [PDF], which shows that by the reviewers’ reckoning, almost all of the guidelines were low quality, but which was particularly harsh on the Rafferty statement.)

So no, it isn’t particularly surprising that the HHS didn’t “consult with” the American Academy of Pediatrics in producing its report, especially given that the HHS team specifically cited the AAP’s guidelines as low quality, drawing on the aforementioned Cass/York reviews:

Now, the AAP claimed in its statement that the “policy and intentions behind our recommendations were cited throughout [the HHS report] in inaccurate and misleading ways,” but again — no details and no, they won’t answer any follow-up questions. It’s unclear to me how the HHS report distorts the AAP’s troubling recent history in this area. This seems more like an AAP problem than an HHS problem, to be honest.

That’s it for Part 1. In Part 2, which will be up soon, I’m going to critique the responses to the HHS report by Kellan Baker, a leading researcher and activist in this area, and by Science magazine, one of the most important science publications in the world.

(Reminder, for paid subscribers, that my article in The Dispatch is reproduced below.)

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Questions? Comments? Information about how the AAP developed its guidelines? I’m at singalminded@gmail.com or on Twitter at @jessesingal.

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HHS Releases Landmark Review on Youth Gender Medicine

The report is productive. The conversation it joins is anything but.

By Jesse Singal