AAP Stands By Policy on Gender-Affirming Care for Trans Youth

The American Academy of Pediatrics (AAP) is standing firm in its guidance on gender-affirming care after a small group of pediatricians called for a review of the evidence behind the policy.

Five AAP members originally proposed Resolution 27 at the Academy’s leadership meeting earlier this year, calling for an update to the AAP’s 2018 policy statement outlining medical recommendations for transgender and gender-diverse youth. The guidance supports the use of puberty blockers and cross-sex hormone therapy following an evaluation for gender dysphoria.

The resolution, which was proposed again at an August AAP leadership meeting but failed to pass, stated that other countries are reconsidering hormone therapy as a first-line treatment and that the AAP should do the same.

However, the AAP has said that this mischaracterizes its current policy, which does not recommend hormone therapy as a first-line treatment, but rather promotes following a systematic, collaborative evaluation by clinicians and mental health professionals.

In a blog post, AAP President Moira Szilagyi, MD, PhD, said a resolution isn’t needed to prompt a review of the evidence on care for transgender youth because that is a “routine part of the Academy’s policy-writing process.”

Additionally, Szilagyi stated that the critics of the “gender-affirming care policy mischaracterize it as pushing medical or surgical treatments on youth; in fact, the policy calls for the opposite: a holistic, collaborative, compassionate approach to care with no end goal or agenda.”

She added that “there is strong consensus among the most prominent medical organizations worldwide that evidence-based, gender-affirming care for transgender children and adolescents is medically necessary and appropriate.”

Additionally, Joshua Safer, MD, executive director of the Mount Sinai Center for Transgender Medicine and Surgery in New York City, told MedPage Today via email that no other countries “are reconsidering the use of hormones and surgeries as first-line treatment for transgender children because hormones and surgeries are not first-line treatment for transgender children.”

“First-line interventions include mental health intakes and social adjustments,” he said. “Puberty blockers sometimes follow.”

The physicians who brought the resolution say they’re being sidelined and that the AAP changed its processes to block discussion of Resolution 27, according to reports.

The AAP, however, said its process worked just as it should have — and that the resolution did not advance because the majority of its membership did not agree with it.

Mark Del Monte, JD, CEO of the AAP, explained the resolution process to MedPage Today.

Any member of the AAP can propose a resolution, which are advisory directives to the board, Del Monte said. Once these resolutions are submitted, the chairs of internal committees can co-sponsor them. Once resolutions receive that co-sponsorship, they can be processed internally by a reference committee, and ultimately go to a vote.

If a resolution does not receive sponsorship prior to the meeting, there is an opportunity for its sponsors to present it for co-sponsorship on the floor, Del Monte added. Resolution 27 received neither form of sponsorship, he said.

Genspect, an international non-profit organization that calls for a “wider range of treatment options” for transgender and gender-questioning children, recently wrote an open letter to the AAP stating its discontent with the Academy’s approach to care for these youth.

Genspect members charged the AAP with stifling conversation around the proposed resolution, accusing it of creating a new rule to block member comments on this proposal. “We were very disappointed to learn that the AAP leadership chose to specifically disallow pediatrician comments on Resolution 27, omitting it from the list in the link sent to pediatricians soliciting their comments,” it stated.

However, Del Monte said that resolutions that do not receive co-sponsorship are not eligible for member comment, per Academy policy.

“I can just say simply and clearly, there were no rule changes associated with Resolution 27,” Del Monte said. “That is not correct.”

Julia Mason, MD, a pediatrician in Oregon, was one of the authors of Resolution 27, and works with Genspect. Mason did not return a request for comment as of press time.

While clinicians agree that more healthcare options and further studies are needed to better support transgender youth, there is a concern that groups like Genspect, which aim to challenge the current approach to youth transgender care, are fueling a political debate that will erode access to transgender medicine.

Szilagyi condemned efforts from state legislatures and other groups to restrict gender-affirming care, stating that they have a “chilling effect” on access to care for this population.

“The people who suffer the most from this discrimination are of course the children and teens just trying to live their lives as their true selves,” Szilagyi said. “Pediatricians will not stay silent as these lies are waged against our patients and our peers.”