What Happened Inside the AAP: Fallout

Part 2: Trials and Tribulations

Plaintiff requests that this Court hold Defendants accountable for their wrongful acts. Plaintiff demands judgment against all Defendants including compensatory and punitive damages to the maximum amount allowed. —Excerpt from complaint filed in Ayala v. AAP

Last week we learned how the American Academy of Pediatrics came to embrace the medical model of ‘affirmative care’ for the newly emergent, fast-growing population of gender-questioning kids and teens.

Here’s a recap of Part 1: In 2018, the AAP’s executive board adopted a policy statement drafted by a medical student who was just then finishing his gender-specialist resident training at Brown University. The Gender Policy Statement, also known as the Rafferty Statement (nicknamed for its author, Jason Rafferty), quietly became the AAP’s official guidance for its 67,000 member pediatricians across the United States. The Statement introduced a whole new model of care — ‘affirmation only’— which was conceived and promoted by the trans-advocacy group WPATH (World Professional Association for Transgender Health) in its 7th and 8th Standards of Care.

‘Affirmation’s’ uniquely patient-centered view appeals to a specific niche of academics who, when it comes to gender, embrace what may be best described as an ‘avant-garde’ approach to treatment in that it rejects the constraints of traditional science — i.e., evidence, data, aversion to unnecessary risk — in favor of an expansive, ‘possibilian’ vision of gender embodiment goals. This group finds a welcoming home in the vanguard gender clinics of America’s university teaching hospitals. Its anti-scientific approach to medicine is perhaps tolerated in proportion to the powerful revenue streams that flow from the gender clinics toward their host institutions; but I’m speculating on that point.

To be precise: ‘affirmative care’ places the patient, whether aged 3, 13, or 30, in command of the diagnosis, full stop. It requires that any patient, of any age, regardless of co-morbidities like trauma, OCD, or severe non-verbal autism, be treated according to the following protocol:

Ask the patient* what his/her/their gender is, affirm the response, and provide endocrine interventions and/or surgical treatments according to his/her/their stated desires for aesthetic embodiment of the target gender; whatever that means to him/her/them.

*or the adult guardian, if the patient is preverbal or otherwise nonverbal

For no one knows better than the patient which gender identity will ultimately bring ‘congruence.’

WPATH-aligned clinicians believe ‘gender congruence’ is the necessary pathway to physical and mental health. For individuals experiencing gender incongruence, the single remedy is ‘transition.’ Once ‘transition’ is underway, ancillary mental health conditions are expected to resolve, because those conditions are believed to be symptoms of the underlying ‘gender incongruence.’

Nothing in the previous paragraph is supported by scientific research. Neither is it supported by qualitative outcome studies, of which there are none. It is, nevertheless, regarded as the ‘gold standard’ of transgender healthcare by the august institutions (Brown University, for example) that host America’s most prestigious youth gender clinics. (Again, whether or not this has to do with those institutions’ profit/loss considerations is beyond the scope of this article.)

We can argue the idea of patient-directed care on the merits for adults; but if you’ve ever been, or known, a child, the idea of extending this much agency to toddlers and ‘tweens might give you pause. That’s in fact a justifiable reaction: recall that the affirmation model arrived at the AAP (in the form of the Rafferty Statement) unaccompanied by any supporting clinical evidence. Five years later, this detail finds both the Academy and Dr. Rafferty (plus Dr. Forcier and other, less prominent colleagues) in the awkward position of having to defend the science behind ‘affirmation’ in a court of law, not typically considered an avant-garde milieu.

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The plaintiff in Ayala v. American Academy of Pediatrics is Isabelle M. Ayala, a twenty-year-old woman whose ill-fated ‘transition journey’ was co-piloted by Defendant Dr. Jason Rafferty and colleagues including his mentor, Dr. Michelle Forcier. Isabelle’s story is detailed in a 62-page complaint alleging medical malpractice, fraud, gross negligence and civil conspiracy, which is where the AAP is implicated. I will summarize it here, with passages copied verbatim from the legal filing in italicized blocks.

Isabelle was 13 when she moved from Florida to Rhode Island with her father and half-brother following her parents’ separation. She recalls a stressful, difficult childhood made dramatically more so following a traumatic sexual assault when she was just seven.

The following year, at age eight, Isabelle experienced the onset of precocious, or ‘early-onset’ puberty, “all too often a consequence for sexual assault victims,” according to the complaint.

‘Puberty, and the changes that came with it, “just didn’t feel right at all” in Isabelle’s view. The sexual trauma haunted her and contributed to a profound insecurity that pushed Isabelle to begin looking for help. Around age 11, as her body continued conforming to that of a woman and her apparent body dysmorphia persisted, Isabelle began cutting herself, often doing so multiple times a day. Around this time, she began engaging substantively with social media for the first time, creating profiles on Instagram, Kik, and Tumblr, among others. These social media interactions introduced Isabelle to the concept of being “trans,” an idea that immediately gained traction in her mind since Isabelle’s life experiences to that point taught her that to be a woman is to be vulnerable [to harm].’

Not only does ‘coming out as trans’ promise a clean slate as someone new, untainted and waiting to be curated by the child’s imagination (guided by her favorite female-to-male influencers); it also provides a detailed, step-by-step road map beginning with ‘coming out’ to her friends, which Isabelle did over the next few months, while her mental health continued to decline.

Soon after their move to Rhode Island, her father arranged to have her evaluated by the Hasbro Pediatric Gender Clinic team in Providence.

‘At her new patient visit on February 8, 2017, within two weeks of her 14th birthday, the clinician noted [...] Isabelle’s previously diagnosed ADHD, depression, and anxiety, and her “significant scarring on [her] bilateral upper thighs,” evidencing her years of cutting.’

At this initial visit, Isabelle also reported a recent suicide attempt, and ‘daily thoughts about wanting to die.’ She left that appointment with “information on youth pride, specifically the transgender group on Tuesday nights.” A week later, an appointment with a psychiatrist at the clinic yielded this conclusion:

‘Isabelle was “transgender” and the reason for her reported suicidal ideation was that she wanted to “start hormone therapy” but that her mom—who “was not involved”—was “blocking [her] treatment.”

As it turns out, Isabelle had not previously attempted suicide after all. [Rather,] trans ideologues on social media taught her that in order to progress toward the medical gender transition that she was convinced would help her, she needed to make her situation sound serious. That is, she was coached online that in order to get testosterone, she needed to falsely report a suicide attempt. Isabelle has since learned this is a common tactic “trans elders” and other influencers online suggest to children who think they need “gender-affirming” cross-sex hormone therapy.’

Not knowing her suicide narrative was contrived, the psychiatrist admitted Isabelle to the inpatient psych unit for a seven-day period. This was the setting of her first encounter with Dr. Rafferty, to whom she stated the following:

“[I] would like to start on testosterone ‘but my mother said she would not let me until I am an adult and she no longer has any say.’” “‘I want everything’ to transition towards a more masculine expression.” “I would like to switch bodies with a boy if I could.” “I would like a penis.” At that same meeting, however, Isabelle also shared with Dr. Rafferty a major hesitation regarding her desire to medically transition, namely, “that [she] might want to have a biological child.” She further explained, “[g]iving birth really fascinates me and I think it is a beautiful thing.”  [A]fter a single visit for less than an hour with Isabelle, and despite having access to all the notes from her prior visits to his clinic listing her profound mental health issues and history of deep trauma, Dr. Rafferty—then still a resident—reached the conclusions that (1) Isabelle would benefit from being put on cross-sex hormones that would radically alter her body, yet somehow cure her underlying depression, anxiety, post-traumatic stress disorder, and other co-morbidities, and (2) based on the minutes he had spent with her, she met diagnostic criteria for such radical cross-sex hormone treatment. And the only stated concern Dr. Rafferty acknowledged was that Isabelle’s mother—who had just flown up from Florida to be with her daughter when she learned of her inpatient admittance—might refuse to let her take cross-sex hormones.

Isabelle was discharged from the psych unit on February 22, 2017. In a video conference three weeks later among Isabelle’s parents and her treatment team,

Isabelle’s mother stated again that, “she and [Isabelle’s] father are ‘not ready’ for [Isabelle] to start hormone[s] and would like to discuss totally reversible interventions first.” Dr. Rafferty, Defendant Wagner, and/or Dr. Morris made several fraudulent representations, which but for those representations Isabelle’s mother would not have consented to her receiving cross-sex hormone treatment. Specifically, these Defendants lied to Isabelle and her parents by telling them that (1) the only treatment for her gender dysphoria and related mental health issues was cross-sex hormonal treatment, and (2) that cross-sex hormonal treatment was the accepted and sole course of action in the medical community and backed by the current body of scientific research. These outright misrepresentations, of course, were entirely consistent with and indeed a byproduct of the fraudulent Gender Policy Statement Dr. Rafferty (and other Defendants) had been working on for the better part of a year at this point. 

[T]hey compound these factual misrepresentations by continuing to pressure and deceive Isabelle’s parents that if they did not consent to cross-sex hormone treatment, Isabelle would kill herself, asking them if they would prefer to have a dead daughter or a living son. Ultimately, these tactics worked, as by the end of that meeting, her mother caved to their pressure and coercion.

Isabelle was prescribed  a “low dose” of depotestosterone cypionate, 20mg/weekly. At her first follow-up appointment April 10, Isabelle said she was ‘hoping to go up on T.’ Accordingly, her dose was tripled that day. The following timeline tells the rest of the story:

May 15, 2017: Isabelle presented with “profound depression with intermittent suicidal ideation.” But because she also “report[ed] initial desirable effect on Testosterone,” Rafferty increased her escitalopram, a medication used to treat depression, to address this concern, and left her 3x higher testosterone dose unchanged.

June 19, 2017: Rafferty declared that Isabelle was “stable with minimal depression and anxiety and no active suicidal ideation,” and increased her testosterone dosage to 80mg/weekly.

September 22, 2017: now six months into taking testosterone, Isabelle reported ongoing depression despite the increased dosage of escitalopram.

October 2, 2017: Isabelle was sent home from school for having a panic attack. She visited the Hasbro Children’s Clinic that day and saw Defendant Dr. Forcier. She told Dr. Forcier that she “had been increasingly depressed and anxious over the past several months.” Dr. Forcier did nothing to slow down Isabelle’s testosterone ingestion or the transition process.

October 20, 2017, Isabelle saw Dr. Rafferty, who increased her prescription for escitalopram to treat her worsening depression, noting that there was “still room to go up” further on the dosage if her depressive feelings and thoughts continued.

November 3, 2017, Isabelle had another appointment with Dr. Rafferty, during which Dr. Rafferty coached Isabelle about “being open with [her] mother (and father) around [her] dysphoria and gradually working up to discussing surgery.” Despite her worsening depression, which Rafferty stated months prior needed to be controlled to further her gender development goals (i.e., be recommended for surgery), Rafferty continued to promote medical transition as the solution.

On or around November 16, 2017, Isabelle attempted suicide. Isabelle reported the suicide attempt to her therapist on November 30, 2017, and was admitted on an inpatient basis for suicidal ideation from December 1, 2017, to December 15, 2017. During this inpatient stay, she discontinued use of escitalopram and was put on fluoxetine, another antidepressant.

In her first appointment with Dr. Rafferty after this inpatient stay on December 29, 2017, he increased her dosage of fluoxetine. He did nothing regarding her extraordinarily high testosterone dosage or attempt to slow down her transition treatment.

A month later, Dr. Rafferty’s notes on a January 19, 2018, visit with Isabelle include that she has “no history of trauma,” a clearly inaccurate statement that indicates Dr. Rafferty either did not bother to investigate and explore her deeply traumatic past or simply chose to ignore it.

Isabelle saw Dr. Rafferty a few more times before she moved back to Florida in June 2018, but not before Rafferty provided her with “plenty of refills” of testosterone on her last visit with him as she was “moving to FL tomorrow.” At the time, she was still battling her depression and anxiety. Dr. Rafferty did nothing to ensure that she would continue to receive appropriate treatment (e.g., have her hormone levels monitored by an endocrinologist), nor did he ever follow up with her to ensure she was continuing to receive medical care, a particularly glaring omission given that he had sent her off with an overprescription of testosterone.

After returning to Florida, Isabelle continued to take testosterone for roughly another year. However, as she distanced from the control and influence of the Defendants at the Hasbro Children’s Hospital and Lifespan, she decided to quit taking testosterone “cold-turkey.” Off the cross-sex hormones, she gradually grew out of her gender dysphoria and began to become more comfortable with her female body, altered as it was from taking testosterone. She realized she was not a boy and never could have been one. Instead, she realized that her mental health issues and discomfort in her body were likely the result of her traumatic childhood and other mental health co-morbidities—a realization any competent physician would have also realized or at least explored—and detransitioned.

The consequences of Isabelle’s treatment are severe, and some are not yet knowable. Those that affect her physical and mental health today include:

• significant vaginal atrophy

• a permanently altered voice

• excess facial and body hair

• weakened bone health

• a diagnosis of Hashimotos’s disease, an autoimmune condition associated with male hormones

The unknown possibilities include infertility, increased risk of cancer and heart disease, and future mental health challenges. Isabelle continues to suffer episodes of anxiety and depression, which are now complicated by regret —and, one imagines, anger.

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Of course, the plaintiff’s complaint only offers one side of the story. Until the case unfolds, we’re left to speculate as to how the AAP and the individual defendants will argue their lack of culpability.

In the meantime, I’m wondering about another group of interested, and potentially injured, parties: the 67,000 pediatricians who make up the AAP’s membership. How will this case, and others in the pipeline, impact them? Also: how have they responded to clinical guidance from the AAP that asks them to pretend an obvious material fallacy?

If anyone in that group is reading this, I would love to hear from you.