What Happened Inside The American Academy of Pediatrics?

Part 1: A remarkable human drama chronicled in 3 acts

Now seems like a good time to examine the American Academy of Pediatrics and its role in the promotion of ‘affirmative’ gender medicine for kids. It’s timely because a potentially-major lawsuit — the first to be leveled at the AAP — was filed last month, by a 20-year-old detransitioner named Isabelle Ayala. The events that left the AAP exposed to legal action are strangely uncomplicated but no less astonishing for that fact.

The indispensable narrator of the AAP story, who doubles as a straight-up action hero in the battle for evidence-based care, is Dr. Julia Mason, a ‘workaday pediatrician’ in Portland, Oregon. She is the source of the information that follows.

Many readers will be familiar with Dr. Mason. She is a founder of SEGM, the Society for Evidence-based Gender Medicine, and she’s been a guest on numerous podcasts. The one I found most valuable was her interview with Wesley Yang in September, 2023. You can listen to it here. This article will outline the remarkable events described in that conversation which led to the AAP’s exposure to serious medical ethics charges. The story has three key players: Dr. Mason, Dr. Jason Rafferty, and Dr. James Cantor. Without further ado…

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ONE — Dr. Mason

Julia Mason’s medical practice is situated in a community near Portland that isn’t an ROGD [rapid onset gender dysphoria] hotspot; her patients’ families aren’t the highly-educated suburban progressives whose daughters have mostly been the vanguard of adolescent trans-identification. In 2019, Dr. Mason had just two patients (both girls) who presented with gender dysphoria and sought referral to the nearby gender clinic. The first girl was convincing in her ‘trans-masculine’ ambitions, and Dr. Mason wasn’t surprised when the clinic prescribed her testosterone. The second patient was not convincing as a dysphoric would-be male, yet she and her mother were determined to be evaluated at the gender clinic; so Dr. Mason signed the referral, assuming the trained specialists at the clinic would make a differential diagnosis and prescribe psychotherapy in her case, not hormones.

When Patient 2 was quickly approved for the same hormone treatment as Patient 1, Dr. Mason had questions which she began posing to her professional governing body, the American Academy of Pediatrics, of which she was a ‘fellow’; i.e., a regular member with voting privileges that come with paid annual dues of $700.

Her voicing of concerns regarding diagnostic ambiguity and the ‘affirmation’ protocol triggered a perplexing sequence of dodges and weaves by an organization we might have assumed works for children but is technically a professional membership society that represents doctors, and whose chief executive is a lawyer. (Those last two points aren’t meant as accusations, just descriptive details.) 

Frustrated by the bureaucratic hurdles she confronted at the AAP, Dr. Mason joined forces with a few other concerned professionals to establish SEGM as a hub for unbiased gender-related research and information. After years of negotiating the AAP’s suspiciously obstructionist procedures for airing concerns about gender medicine, she and a few other doctors finally succeeded this year in coaxing the organization to undertake a systematic review of the evidence on which its guidance is based. That review is currently pending with no commitment from the AAP as to when it will be done. They are adhering to the current ‘affirmation-only’ guidance in the meantime, but at least the intention of measuring the current protocols against high-quality evidence has been stated for the record.

So that’s the background. The essential question these ‘first responders’ were asking is the same nagging question we all arrive at sooner or later: 

How did the AAP formulate its guidance on youth gender medicine, and where is the evidence base to support it?

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TWO — Dr. Rafferty

A year earlier, in 2018, a young resident named Jason Rafferty was completing his training at Brown University Medical School under Dr. Michelle Forcier, one of the leading pioneers of ‘affirmative gender care’ for youth. (Dr. Forcier gave a memorable interview to Matt Walsh for his film “What Is A Woman?”) On the verge of becoming an MD gender specialist, Rafferty was eager to spread the good news of childhood medical sex-change and expand access to lifesaving care for the ‘trans’ children of America. A critical step would be to codify the teachings of WPATH’s 7th Standards of Care* into AAP guidance for all pediatricians to follow.

So Dr. Rafferty wrote a policy statement titled “Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents,” and pitched it to the AAP, urging the organization to embrace progress and be on the right side of history, as Dr. Mason guesses the argument went. The AAP executive board did in fact adopt the statement as official AAP physician guidance, but they tacked on a most unusual equivocation — someone might even characterize it as a disclaimer, in, say, a future deposition — stating that Rafferty’s new rules were ‘drafted and reviewed by the author’, who was ‘solely responsible’ for their content.

And so it was that the world’s pre-eminent authority on children’s healthcare became a disciple of WPATH, the World Professional Association for Transgender Health [fine print notwithstanding], whose teachings give us to understand that the only recognized authority in matters of a child’s gendered soul is the child theirself, and that a ‘wrong [i.e., natural] puberty’ can just ruin everything if not prevented in time. Also: any who dispute these learnings shall be tried for Conversion, which is a very bad thing indeed.

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THREE — Not so fast! hollers Dr. James Cantor later the same year (2018)

Blessed be the fact checkers.

Dr. Cantor, a world-renowned, much-published clinical sexology researcher with 30 years of experience, happened upon the Rafferty statement and cried foul — loudly — in a scathing claim-by-claim dismantling of the whole misbegotten artifact. Cantor’s takedown is a recommended read, accessibly worded with highlights like this:

“It was quite a remarkable document: Although almost all clinics and professional associations in the world use what’s called the watchful waiting approach to helping GD [gender dysphoric] children, the AAP statement rejected that consensus, endorsing only gender affirmation. With AAP taking such a dramatic departure from other professional associations, I was immediately curious about what evidence led them to that conclusion. (Extraordinary claims require extraordinary evidence, and all that.) As I read the works on which they based their policy however, I was pretty surprised...rather alarmed, actually: These documents simply did not say what AAP claimed they did. In fact, the references that AAP cited as the basis of their policy instead outright contradicted that policy, repeatedly endorsing watchful waiting. The AAP statement was also remarkable in what it left out—namely, the outcomes research on GD children…. The literature on outcomes was neither reviewed, summarized, nor subjected to meta-analysis to be considered in the aggregate— It was merely disappeared.”

And this, regarding conversion therapy:

AAP's claims struck me as odd because there are no studies of conversion therapy for gender identity.  Studies of conversion therapy have been limited to sexual orientation—specifically, the sexual orientation of adults—not to gender identity, and not of children in any case.  The article AAP cited to support their claim (reference number 38) is indeed a classic and well-known review, but it is a review of sexual orientation research only.  Neither gender identity, nor even children, received even a single mention in it. Indeed, the narrower scope of that article should be clear to anyone reading even just its title: “The practice and ethics of sexual orientation conversion therapy” (Haldeman, 1994, p. 221, italics added).

Ouch! Dr. Cantor must have made that a rough day — rough week, even — for Dr. Rafferty. But who would say it’s a crime to swing for the fences and miss, especially when we’re just starting out in the career/passion project we’ve worked so many years to achieve? If we’re lucky academics, our rookie mistakes will be caught in the safety net of peer review before they escape the lab, so to speak, where they could otherwise do real damage. James Cantor’s fact-check of the Rafferty paper was a voluntary contribution to scientific integrity in the interest of public health. You’re welcome, AAP.

The AAP recognized their failure to perform due diligence before rubber-stamping Rafferty’s radical new roadmap for medical experiments on healthy children. The board humbly acknowledged their debt to Dr. Cantor for rescuing the association’s reputation from the jaws of disaster, awarding him lifetime honorary ombudsman status and appointing an outside commission to investigate AAP’s shocking breach of institutional responsibility, so that it can never be repeated.

Yeah no, unfortunately, that’s not what happened. As Dr. Mason tells it, there’s no evidence to suggest AAP leadership ever bothered to read James Cantor’s thorough, factual refutation of their new policy statement. There’s every reason to believe they never checked Dr. Rafferty’s work before adopting his novel theories as the AAP’s own. If they had, there would be no Ayala v. American Academy of Pediatrics, in which four physicians are also named as individual defendants. One of those names will ring a bell when we pick up the legal thread next week. Stay tuned!

* SOC-7 text begins on page 22 of this link