What a review of gender-affirming care research by a top pediatrics group actually means

When the American Academy of Pediatrics reaffirmed its support for gender-affirming care earlier this month, and called for a systematic review of the evidence, some swaths of the public saw the move as casting doubt on the benefits of such care.

But the AAP and other experts say the systematic review only indicates their confidence in the current standards of care, and their awareness of a need to stay on top of the evidence amid a changing political landscape in which anti-trans legislation — particularly targeting youth access to health care — has proliferated.

“That context mattered to the pediatricians who worry about any intrusion into the physician-family dynamic or the doctor-patient relationship about gender-affirming care, or anything else,” Mark Del Monte, the CEO of AAP, said. After a “careful discussion,” the vote to reaffirm the organization’s 2018 policy statement was unanimous.

The move also reflects AAP’s practice of regularly reviewing research as the organization looks to develop new guidelines for clinicians in the years ahead. AAP represents 67,000 pediatricians, and clinicians across the country turn to the professional organization for guidance on how to care for their patients.   

Katy Miller, the medical director of adolescent medicine at Children’s Minnesota who was not part of the vote, said that while pediatricians are “continuing to follow best practice … it will be nice to have that affirmed by a formal, systematic review.”

Several experts also told STAT that they disagreed with how the AAP’s decision has been compared to policy changes on gender-affirming care in Europe.

In Norway, officials are currently considering restricting gender-affirming care for minors to only treatment offered in registered clinical trials. Similar requirements connecting youth treatment to research exist in both Sweden and England. British authorities have also closed London’s Tavistock clinic in favor of opening more regional centers to meet the high demand for care.

“There is a lot of intentional misrepresentation going on of what is actually happening in Europe,” said Kellan Baker, executive director of the Whitman-Walker Institute. “When you’re talking about linking care to research and saying, ‘you can get this care as long as you’re also participating in scientific research that is going to advance the field,’ that’s not a restriction.”

Other experts argued that any research requirements whatsoever constitute a restriction on care, because they introduce new hoops for people to jump through. But unlike the U.S., no European country has outright banned gender-affirming hormones or surgery for youth. In the U.S., 22 states have enacted bans of gender-affirming hormones, surgery, or both, though a handful of these bans have been blocked by federal judges.

Avery Everhart, an assistant professor at the University of British Columbia who focuses on transgender health and human rights, said it’s not particularly useful to compare how health care is delivered in a small country with a national health system, where research is easier to conduct in a centralized way, and America’s byzantine health care system, with its patchwork laws and siloed data sets.

Everhart said that researchers need to better incorporate the geopolitical and sociological context in which their work is done.

“If comparisons are to be made, then it needs to be done in a way that is very clear about not only the context in which things happen, but also who it is that’s conducting the research and who’s not involved,” she said.

The AAP’s review of evidence will include any research that occurs in Europe, Del Monte said. While there is a breadth of evidence on the benefits of gender-affirming care, especially when it comes to youth mental health, experts say more is needed on the physiological questions and concerns that trans people have about their bodies.

“It is really annoying that we’re constantly stuck with the question of ‘should trans care be allowed?’ Because it prevents us from getting into the question of ‘how do we best do trans care?’” said Florence Ashley, a researcher, bioethicist, and law professor at the University of Alberta.

Trans people have a wide range of goals for their bodies and lives — but there’s little research on attempting to vary hormone dosing regimens. Different starting doses of estrogen may lead to faster or slower immediate breast growth, for example, but also may affect the total amount of growth that is possible.

“We don’t really know what the options are and how they differ in practice,” Ashley said. “If we had the studies, I suspect people would want to take a bit more of a customized approach based on what their priorities are,” they added.

AAP’s updated guidance will not be published until at least 2024, a representative said. Until then, clinicians will continue to provide the range of gender-affirming care as outlined in existing clinical guidelines from the World Professional Association for Transgender Health and the Endocrine Society.

When AAP does publish its updated documents, Baker said that “one would hope” the official guidance would influence federal and local policies, but he acknowledged that may be unlikely given the politicization of care.

“What we’re seeing instead is a wholesale turning away from the evidence in favor of these really politicized ideological moves that have nothing to do with the health and well-being of trans people and everything to do with trying to make it impossible for transgender people to be that they are,” he said.