US paediatric leaders back gender affirming approach while also ordering evidence review

The American Academy of Paediatrics (AAP) reaffirmed its policy supporting the gender affirming model of care while at the same time announcing that it would commission a systematic review of the evidence and “develop an expanded set of guidance” on medical treatment in minors.1

The announcement marks a shift for the AAP, which last year defended its 2018 policy statement 2 to The BMJ as being based on a “rigorous evidence review.”

The policy recommends “developmentally appropriate healthcare” including medical and surgical intervention.

But some specialists have criticised the academy for promoting treatments whose outcomes lack the certainty afforded by a systematic review of the evidence.3

Gordon Guyatt, distinguished professor in the department of health research methods, evidence, and impact at McMaster University and one of the founders of evidence based medicine, explained to The BMJ that with few exceptions, strong recommendations should not be based on low quality evidence. And “trustworthy guidelines” follow systematic reviews, not the other way around 4

Existing systematic reviews567 have led countries including the UK, Finland, and Sweden to promote a cautious approach that prioritises psychotherapy for minors experiencing gender dysphoria or incongruence while restricting puberty blockers to clinical trials.

Norway’s Health Care Investigation Board (Ukom) recently recommended updated national guidelines based on systematic reviews, calling hormonal treatments in minors investigational.8

Hillary Cass’s interim report on England’s gender services stated that “evidence on the appropriate management of children and young people with gender incongruence and dysphoria is inconclusive both nationally and internationally.” A final report is expected this autumn.

Advocates point to the 2018 AAP statement as demonstrating medical consensus on the provision of treatments like gonadotrophin releasing hormone analogueues to suppress pubertal development, sex hormones including oestrogen and testosterone, and, “on a case-by-case basis,” surgeries in adolescents.

The statement informs clinicians that “many medical interventions can be offered to youth who identify as transgender and gender diverse.” This population, even before the onset of puberty, “know their gender as clearly and as consistently as their developmentally equivalent [cisgender] peers,” according to the statement. An approach of “watchful waiting” to see how a young patient’s identity develops is “outdated” and “does not serve the child because critical support is withheld.”

For two years in a row, AAP members submitted formal resolutions to the executive board asking “that the academy commit to the principles of evidence based medicine by eschewing narrative and other types of non-systematic reviews as the basis for its recommendations” and either use existing systematic reviews or commission its own.

A resolution submitted in April with two dozen signatories also asked that an “urgent statement” be made urging paediatricians “to exercise extreme caution in transitioning minors with hormones and surgeries pending the results.”

The lead author of these resolutions, Julia Mason, a paediatrician in Gresham, Oregon, and a founder of the Society for Evidence-Based Gender Medicine, told The BMJ she is “gratified” that AAP is “making a commitment to look at the evidence” but is “disappointed they are not taking a precautionary approach.”

AAP announced that its policy update process will be “transparent and inclusive,” and will “invite members and other stakeholders to share input.”

Mason said, “I’m hoping that means that they will include clinicians with different views, detransitioners, and parents.”