Pediatric group says kids should not talk to parents about puberty blockers
Thousands of pediatricians convened in Anaheim, Calif., in early October for the American Academy of Pediatrics’ (AAP) annual conference. The group, which boasts 67,000 members in the US and around the world describes itself as “dedicated to the health of all children.”
So some audience members were shocked when Dr. Morissa Ladinsky, an associate professor of pediatrics at the University of Alabama at Birmingham, lauded a transgender teenager for committing suicide.
In an address about “standing up for gender-affirming care,” Ladinsky eulogized Leelah Alcorn, an Ohio 17-year-old who, in Ladinsky’s words, “stepped boldly in front of a tractor trailer, ending her life,” in 2014, after leaving a suicide note that “went viral, literally around the world.”
Ladinsky’s remarks were captured on video by a horrified onlooker, Oregon pediatrician Dr. Julia Mason, who expressed outrage on Twitter that Ladinsky was “glorifying suicide,” an act she described as “unprofessional and dangerous.”
That isn’t just Mason’s opinion. Technically speaking, it is also the official stance of the AAP, whose website for parents, healthychildren.org, explicitly warns that “glorifying suicide” can have a “’contagious’ effect” and inspire others to take their own lives.
Reached for comment, Ladinsky expressed “regret” about her choice of words and said it was “never my intent” to glorify self-harm. But how did this esteemed doctor wind up telling a group of physicians that a teen had, as she put it, “boldly ended her life?”
In any large organization, some members are bound to hold fringe views. But Ladinsky, who has devoted her career in part to facilitating the gender transition of teenagers, including by challenging state laws that restrict the kinds of treatment physicians can provide to them, is hardly an outlier at the AAP. And the AAP is an organization that matters a great deal.
Founded in 1930 as an offshoot of the American Medical Association, the AAP is first and foremost a standard-setting body. It outlines best practices for the nation’s pediatricians, advises policymakers on public-health issues and, for many parents, is the premier authority on raising healthy kids.
In recent years, it has also become a participant in America’s culture wars. Judges have deferred to the group’s expertise in high-stakes court cases about children with gender dysphoria, who the AAP says can start socially transitioning at “any” age. During the height of COVID, schools masked toddlers — including toddlers with speech delays — based on the guidance of the AAP. Sports leagues and after-school programs mandated the COVID vaccine after the AAP strongly recommended it, even as concerns mounted about its association with myocarditis, or inflammation of the heart muscle, in young males.
Though the organization’s guidelines are framed as the consensus position of the AAP’s members, only a handful of physicians had a role in shaping them. Instead, insiders say, the AAP is deferring to small, like-minded teams of specialists ensconced in children’s hospitals, research centers, and public-health bureaucracies, rather than seeking the insights of pediatricians who see a wide cross-section of America’s children.
They also say a longstanding left-wing bias — over two-thirds of pediatricians are registered Democrats — has accelerated, turning the organization into a more overtly political body that now pronounces on issues from climate change to immigration. As rates of gender dysphoria exploded and the COVID-19 pandemic hit, that bias seeped into the organization’s medical policy recommendations, unchecked by discussion or debate.
In 2016, the AAP established a committee on “LGBT Health & Wellness” to support “children with variations in gender presentation.” Four of the committee’s six members — Jason Rafferty, Brittany Allen, Michelle Forcier, and Ilana Sherer — work in pediatric gender clinics that prescribe puberty blockers to patients as young as 10 and cross-sex hormones to patients as young as 14.
Those treatments are part of the broader model of “gender-affirming” care that the AAP endorsed in its 2018 policy statement, “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents.” The statement, which represents the official position of the AAP, was written by a single doctor, Rafferty, and does not appear to have been reviewed by anyone else at the organization: Rafferty “conceptualized,” “drafted,” “reviewed,” “revised” and “approved” the manuscript himself, a note at the end of the paper reads. Rafferty did not respond to a request for comment.
“There was clearly no fact-checking,” one longtime AAP member said. “The AAP thought trans was the next civil-rights crusade and got boondoggled by enthusiastic young doctors.”
The 2018 statement was an extraordinary departure from the international medical consensus. Most European countries do not encourage social or physical transition until a child’s gender dysphoria has persisted for quite some time — an approach known as “watchful waiting” — in part because the dysphoria desists on its own in the majority of cases, particularly once puberty hits.
Rafferty, however, called watchful waiting “outdated” and endorsed a “gender-affirming” paradigm, in which transitioning is on the table almost as soon as a child identifies as transgender. Some of the studies he cited to support that conclusion — including a practice guideline from the American Academy of Child and Adolescent Psychiatry — actually undercut it, arguing that, more often than not, “sex-reassignment” should be deferred until adulthood.
Though the policy statement conceded that puberty blockers may pose “long-term risks” to “bone metabolism and fertility,” it did not recommend any prerequisites for obtaining drugs. They could be given out at the earliest stages of puberty — meaning to children as young as 9 — and, Rafferty insisted, were “reversible.” Since then, the gap between the AAP and the rest of the world has only grown.
Many European countries, including Britain, Finland, Sweden, and the Netherlands, are now curtailing or entirely eliminating the use of puberty blockers in children with gender dysphoria, citing both long-term health risks and a lack of evidence that they alleviate the condition.
The AAP has nonetheless maintained its support for the drugs — which it claims have the backing of the “most prominent medical organizations worldwide” — while rejecting calls for more gatekeeping.
“The AAP says kids under 10 can’t cross the street by themselves,” one pediatrician said, referencing the group’s official recommendations on pedestrian safety, “but they can change their gender. How does that make sense?”
The contrast points to a broader tension within AAP guidance: On most kitchen-table issues, from diet to screen time to exercise, the group has long encouraged a kind of safetyism, stressing the need for parental supervision and the pitfalls of pubescent judgment. Yet on trans issues, it has done nearly the opposite, suggesting that minors are mature enough to transition without their parents’ knowledge or consent.
“A family may deny access to care that raises concerns about the youth’s welfare and safety,” Rafferty’s statement says. “In such rare situations, pediatric providers may want to familiarize themselves with relevant local consent laws and maintain their primary responsibility for the welfare of the child.”
It’s a stark departure from the way the group talks about other forms of body modification: One AAP report recommends that “adolescents speak with their parents” before getting tattoos, because they are “permanent,” “difficult to remove” and “involve significant consequences.”
By 2019, Rafferty’s guidance was eliciting quiet concern among rank-and-file doctors affiliated with the AAP. “Normie pediatricians were like, ‘what’s going on,’ ” one doctor said, recalling the hushed conversations she had in the hallways of the AAP’s 2019 national conference, which featured a panel on gender-affirming care. Gender specialists, on the other hand, “considered themselves life-saving heroes.”
Rather than promoting dialogue or compromise between the two camps, the AAP sought to stifle dissent. In October, it urged the Department of Justice to investigate critics of “gender affirming” care, arguing they were spreading “disinformation” that puts lives at risk. That move came after the organization barred the Society for Evidence-based Gender Medicine, which advocates the watchful-waiting approach, from being an exhibitor at its national conference last year.
In August, it also blocked a resolution calling for a review of the AAP’s current guidance on puberty blockers, which the head of Boston Children’s Hospital’s gender clinic, Jeremi Carswell, says are “given out like candy” at her clinic.
The stifling of dissent has created an illusory medical consensus that nonetheless exerts extraordinary influence over public policy and debate. Courts have cited the AAP in cases about transgender children — Eknes-Tucker v. Marshall, for example, in which an Alabama District Court blocked a law banning puberty blockers, cross sex hormones and gender reassignment surgeries for transgender minors (the case is now on appeal). Talking heads, meanwhile, have invoked the AAP to shut down criticism of childhood gender transition.
In October, Jon Stewart berated Arkansas Attorney General Leslie Rutledge after her state passed a law similar to Alabama’s, arguing that she was bucking the AAP’s “peer-reviewed” guidelines. Banning puberty blockers would be as backwards as banning chemotherapy, Stewart said. He did not mention that the Swedish National Board of Health and Welfare had, in February, recommended halting hormonal gender treatment for minors except in tightly limited circumstances.
The National Institutes of Health has funded one study on the long-term effects of puberty blockers, which is being conducted by four university-affiliated gender clinics — including the one at Boston Children’s, the place that acknowledged prescribing blockers “like candy.” The study, which began in 2015, has yet to report its findings, and the authors have not declared any conflicts of interests.
At stake in all this, said Marty Makary, a surgeon and public policy researcher at Johns Hopkins Medicine, is not just COVID lockdowns or puberty blockers but the credibility of the medical establishment itself.
“The AAP still puts out many important recommendations that parents should follow,” Makary said, citing the group’s support for the measles vaccine and its guidance on preventing sudden infant death syndrome. “If parents start to distrust the AAP because of its politicization, I worry we’ll see more pediatric deaths.”
Other doctors described families — including families in deep blue areas — who have developed a reflexive distrust of anything the AAP says.
“I now hear parents mock the AAP over even nonpolitical guidance like breastfeeding recommendations,” a pediatrician in Portland, Ore., said. “They’re just tuning everything out.”
For Vinay Prasad, a professor of epidemiology and biostatistics at the University of California, San Francisco, it’s hard to blame them.
“The reason to trust modern doctors over ancient healers is that more of what we tell you to do is justified by well-done studies,” Prasad said. “But how do we hold that perch when we just make stuff up?”