Summary

In 2018 the American Academy of Pediatrics (AAP), the main US children's doctors' group, issued a policy backing a "gender-affirming" approach for children and teens. It rejected both conversion therapy and "watchful waiting", meaning supporting a child without pushing either way. James Cantor, a psychologist, read the papers the AAP cited and argued they did not back it. Papers cited about conversion therapy were about sexual orientation, and papers cited to criticise watchful waiting actually recommended it. He also said the AAP left out the follow-up studies of children with gender distress, all of which found most stopped wanting to transition by puberty. The piece became influential. In 2023 the AAP kept its policy but ordered a formal review of the evidence. This is one author checking citations, not new data, and the childhood studies it relies on are themselves disputed.

Key findings

• The piece checks the sources cited in the American Academy of Pediatrics' 2018 policy on caring for transgender and gender-diverse children and teens (Rafferty et al.).
• Cantor argues the AAP rejected "watchful waiting", the approach almost all clinics and professional groups used at the time, and backed affirmation as the only acceptable approach.
• He reports that papers the AAP cited against "conversion" or "reparative" therapy were about sexual orientation, not about gender identity in children.
• He reports that several papers the AAP cited to criticise watchful waiting actually supported it.
• He notes that of 11 follow-up studies of children with gender distress, all finding that most stopped wanting to transition by puberty, the AAP cited only one (Wallien & Cohen-Kettenis 2008) and did not mention what it found.
• In August 2023 the AAP reaffirmed its 2018 policy while ordering a formal review of the evidence to guide an update.

Abstract

The American Academy of Pediatrics (AAP) recently published a policy statement: Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Although almost all clinics and professional associations in the world use what's called the watchful waiting approach to helping gender diverse (GD) children, the AAP statement instead rejected that consensus, endorsing gender affirmation as the only acceptable approach. Remarkably, not only did the AAP statement fail to include any of the actual outcomes literature on such cases, but it also misrepresented the contents of its citations, which repeatedly said the very opposite of what AAP attributed to them.

Conclusion

Cantor concludes that the AAP policy statement is not based on the evidence it claims: it omitted the outcomes literature on gender-dysphoric children (every follow-up study finding that most desisted by puberty) and misrepresented its citations, which repeatedly supported watchful waiting rather than the affirmation-only approach the AAP endorsed. The AAP is free to adopt any policy it wishes, he argues, but any assertion that its policy is evidence-based is demonstrably false.