The American Academy of Pediatrics (AAP) recently reaffirmed its 2018 position on youth who suffer from gender dysphoria while simultaneously calling on a systematic review of the evidence of how to treat such children.

Looking back on the AAP’s 2018 statement, as pediatricians, we both agree with the 2018 report that we “must protect youth who identify as Transgender and Gender Diverse from discrimination and violence.” It’s our job to protect children.

However, we do not think the 2018 report is following the millennia-old tenet of “do no harm.” The conclusions included in that 2018 position recommend that youth who identify as transgender have access to “comprehensive, gender-affirming, and developmentally appropriate health care” that is covered by insurance.

The increasing call in the U.S. for the daily release of hormones into young bodies, or extensive surgical procedures, with scant evidence of benefit while our European counterparts are restricting gender transitions for youth is doing more than raising eyebrows. This push, plus demands that it be covered by insurance at a time when so many other claims are being denied is not only potentially causing long-term harm to young people, but further eroding trust in our U.S. medical system.

Those AAP conclusions were published a year after Dr. Rachel Levine, who identifies as transgender and is now a high-level HHS secretary, sent an email to the co-founder of the Children’s Hospital of Philadelphia gender clinic, writing: “I know that we had discussed at US PATH [Professional Association for Transgender Health] the possibility of gender confirmation surgery for young people under 18 years of age. This could include top surgery for trans young men and top and bottom surgery for trans young women. Is there any literature to support this protocol?”

The reply: “I’m not aware of existing literature but it is certainly happening. I think we’ve had more than 10 patients who have had chest surgery under 18 (as young as 15) and 1 bottom surgery (17).”

Despite the lack of evidence, nearly $17 million tax dollars has been spent on pediatric gender transition treatments in recent years in Pennsylvania alone.

“There is not a full range of evidence to support the treatments that we’re using,” said the director of the gender clinic at Chicago’s largest children’s hospital. His reward for not following evidence-based medicine is a $5.7 million grant from the NIH.

The FDA recently issued a warning against using some of the puberty blockers due to short-term neurological side effects. No one knows the long-term effects of introducing the hormones to a young brain or what the forever term use will bring to the future of these patients.

Despite the warnings, 14,726 minors with gender dysphoria started hormone treatment from 2017 through 2021. And 832 irreversible surgeries were performed on minors for gender dysphoria between 2019-2021. These numbers are expected to rise as gender dysphoria diagnoses have tripled between those years, at an accelerating pace.

When the AAP is going about reviewing the evidence, they—and all pediatric professionals—might want to fully dissect a survey that is often cited by proponents of gender transitions for minors: The Report of the 2015 U.S. Transgender Survey. The survey of 27,000 individuals recruited responses using advocacy organizations, and of note, detransitioners were excluded. There were other jarring red flags in this survey: There were no baseline mental health questions of survey respondents, respondents were asked to recall how they felt years earlier, and 25% of respondents came from 3 states (California, New York and Washington). Remarkably, the survey asked respondents if they sought any of a list of “gender-affirming care” and excluded them if they did not seek hormones. Colloquially, we call that cherry-picking.

The survey, put together by a group of self-professed social justice advocates, had very low numbers of adolescents, and yet has been used in recent years to justify the increase in medical treatment of gender-questioning youth.

The Journal “Pediatrics” relied on this survey for a paper in 2020. The same physician author from the 2020 Pediatrics paper used the survey for another “second look” paper. This 2022 second look was funded by the American Academy of Child & Adolescent Psychiatry, itself supported financially by pharma corporations Arbor and Pfizer. Both produce hormones used in gender transitions.

The 2022 second look of the survey spawned a series of sensational headlines. “Trans teens who get gender-affirming hormones are healthier and happier as adults,” trumpeted Today. “Transgender children who get hormone therapy enjoy better mental health,” claimed USA Today.

It’s good that the AAP is performing a systematic review. They would do well to be transparent, thorough and honest. They might want to comment on the perverse incentives that could have led to over-treatment in years past. And above all, they must remember: Primum non nocere.