As the United States stands at a crucial crossroads over the care of young people who have severe distress over their gender, the nation’s premiere medical association for pediatricians has found itself under siege from both sides of this combustible issue.The latest battle in the internecine feud centers on the decision by the association, the American Academy of Pediatrics, to hold its annual conference in Florida.

This evening, just after Hurricane Helene pummelled the Florida panhandle, the AAP is launching its annual conference in Orlando, despite fierce opposition by LGBTQ members and their allies. A months-long investigation conducted by The Sun has revealed that members of the AAP’s LGBTQ affinity group, dismayed by the conference’s location, levied internal protests and threats of a conference boycott at the organization’s leadership. They are furious about the prospect of bringing business to a state that in recent years has passed tough restrictions on abortion as well as approved a series of new laws considered hostile to LGBTQ people. These laws include a ban on instruction about gender and sexuality in the younger grades of public elementary schools; a ban on medical gender treatments for minors; and bathroom-related restrictions for transgender persons.

Some AAP doctors find these Florida laws to be morally repugnant and even consider them hazardous to their personal safety.

From the opposing vantage point, the AAP faces equally fierce objections, both from outside activists and a small but determined group of pediatrician members, over its steadfast support of minors’ access to gender-transition treatments, which this camp generally characterizes as a risky and unproven medical intervention for youths. For years, members of this bloc have criticized the organization for, they say, dragging its feet in commissioning a formal review of the evidence behind pediatric gender-transition treatment, especially as an increasing number of research groups have published such reviews and found the evidence woefully wanting. 

Amid such burgeoning tensions, the AAP leadership quietly declined to pull out of Florida, citing the associated financial burden. Its refusal to relocate the conference to a state considered more hospitable to transgender people was yet another death knell to liberal hopes for resistance from businesses, which once circled the wagons and threatened—to powerful effect—to deny business to states where legislators proposed bills they decried as anti-LGBTQ. But in recent years, Republican-dominated states have introduced such a barrage of these laws and restrictions that the leftwing groups that oppose them have largely given up on boycotts. 

Instead, the AAP sought to mollify its LGBTQ affinity group through various concessions, and in part by remaining resolute in its vocal support for what is known as the gender-affirming care method for minors. The organization has also repeated past efforts to prevent dissent regarding this issue at the conference, its critics say, by refusing entry to a nonprofit group that is critical of such medical interventions for gender-distressed minors. These controversial treatments can include the use of puberty blockers and cross-sex hormones and, sometimes, surgeries to modify sexual characteristics. Of primary concern to skeptics, such treatments pose the risk of rendering young people infertile and saddling them with potentially lifelong sexual dysfunction. Some two dozen people who underwent gender-transition treatment as adolescents or young adults and later regretted it have recently filed suit against their health and mental health providers. 

Most visibly, the AAP has remained ostensibly defiant of the organization’s critics through its selection of a keynote speaker for its conference. In June, the AAP and a major Biden health official were each revealed to have placed what critics have characterized as undue pressure on a major transgender activist-medical organization over the drafting of that group’s influential transgender care guidelines. Far from admitting fault for its role in this successful effort, the AAP instead announced in mid-August that it had bestowed upon that very official the honor of headlining their Florida conference. 

On Sunday, Admiral Rachel Levine, who as the assistant secretary for health at the U.S. Department of Health and Human Services is the highest ranking transgender official in the federal government’s history, will deliver a keynote address at the AAP’s Orlando conference. 

To critics, Dr. Levine’s speakership is a galling confirmation that the AAP will not heed their calls to change course and at least dial back its ardent support for treating minors with gender dysphoria—a psychological condition defined by marked distress related to a misalignment between one’s gender identity and biological sex—with gender-transition medications.  

Dr. Levine, a pediatrician who won a major LGBTQ-medicine award from the AAP in 2021, will speak just days after a group of 20 Republican state attorney generals sent an aggressive and probing letter to the AAP suggesting that the organization has violated state consumer protection laws through its public claims that puberty blockers are “reversible”.

This investigation by The Sun is based on hundreds of pages of internal emails that circulated among both the leadership and rank-and-file members of the AAP, dating back to 2016. The Sun obtained these documents through public-records requests submitted to public universities that employ certain AAP members who used their workplace email accounts to access and participate in these discussions. 

These documents help shed light on the internal workings of a wealthy and powerful medical association that, in the face of both criticism and litigation over its policies regarding children and adolescents who identify as transgender, has remained relatively opaque about the scientific reasoning behind its expressed philosophy on the care of such youths.

These records also help flesh out the otherwise enigmatic portrait of one of the most influential figures in the pediatric gender-care field: the beleaguered and recently media-shy Brown University pediatrician and child psychiatrist Jason Rafferty. The recent leader of the AAP’s LGBTQ affinity group, Dr. Rafferty is sole author of the organization’s policy statement on the gender-affirming care method – a document that, since its publication in 2018, has served both as a bedrock for U.S. gender clinics’ particularly liberal approach to prescribing gender-transition treatment and as a wellspring of controversy. 

This policy statement is a linchpin in a lawsuit against the AAP and Dr. Rafferty and his colleagues. The suit was filed in October by Isabelle Ayala, a young woman who as a minor received testosterone to treat gender dysphoria from Dr. Rafferty’s team in Rhode Island. She later detransitioned – meaning she stopped taking the hormones and reverted to identifying and presenting as her biological sex – and fears she may have damaged her fertility.

During the coming months, the Supreme Court will hear oral arguments in a major case over whether Tennessee’s ban on pediatric gender-transition treatments violates the Equal Protection clause of the Constitution. The high court’s ruling could entrench a lack of access to such treatments in about half of U.S. states. Otherwise, medical malpractice lawsuits like the one against the AAP and Dr. Rafferty which could drive up malpractice premiums for doctors and render such medical interventions increasingly out of reach even in the blue states where legislators have often sought to create sanctuary laws to protect such access. 

As for the coming five days, thousands of pediatricians – those who managed to arrive despite the hurricane – will meet in Disney World’s backyard to discuss and debate the ever-pressing questions of how best to care for the next generation, including LGBTQ-identifying youth.

“The anti-trans movement has won” – despair and conflict within the AAP

Among the various affinity and subspeciality groups, known as sections, that the AAP’s approximately 65,000 pediatrician members can join within the organization is a section concerning LGBTQ health and wellness. This group includes both LGBTQ pediatricians as well as doctors who are concerned with caring for queer youth. Through public-records requests, the Sun obtained numerous emails that this section’s members exchanged through its dedicated listserv.

This listserv is host to impassioned exchanges about transgender issues. In December, one member from Hawaii went so far as to argue for reporting to child protective services certain lawmakers, in particular Republicans in Texas, who established policies that the group saw as harmful to transgender children.

Rachel Silliman Cohen, a child-abuse specialist and pediatrician at Rowan-Virtua School of Osteopathic Medicine in Stratford, New Jersey, is the author of a recent paper in the AAP’s journal, Pediatrics, arguing that denying gender-affirming care to minors is a form of child maltreatment. She responded to the suggestion of reporting legislators to CPS by informing the AAP listserv that “standard mandated reporting processes almost certainly would not address the harm caused by legislators who ban GAC.” However, she then said she and the coauthors of her paper had wondered “whether the mandated reporting model could be used in some way” to target those who thwart access to such care, “(and if so, who reports, who gets reported on, and to whom does the report go?).”

In a December 22 email, pediatrician Alice Turner of Kaiser Permanente in Walnut Creek, California, provided information to the listserv about the Biden administration’s keen interest in defending access to gender-transition treatments for minors and combating state bans against it. She said that she had attended the November 2023 conference in Westminster, Colorado, for the U.S. branch of the World Professional Association of Transgender Health, or Wpath, and that “there were reps from the justice department and the department of Health and Human Services and they were amazing. They are working to fight these laws on the basis of medical necessity and that you cannot discriminate by denying care that you provide to some patients but not to others based on their gender.”

Dr. Turner also said she was “thinking of mobilizing” Kaiser’s “data to show the mental health impact this anti-trans movement has had on” youth who are transgender and what’s known as gender-diverse.

Among the most notable listserv threads obtained by the Sun was a fraught exchange in January during which numerous members expressed fear and loathing over the prospect of the AAP holding its annual conference in Florida in the fall. Multiple pediatricians insisted they would not attend, refusing to spend time and money in a state they saw as hostile to their own identities and values and to their transgender children and patients.

Some doctors called for an organized boycott of the AAP conference if it remained in Florida. Others expressed ambivalence about or opposition to such a bold effort, wanting to show support for LGBTQ pediatricians and patients by advocating on their behalf on the ground in Florida.

One of the most vocal members of this exchange was Debra Koutnik, a behavioral pediatric physician in the Southern Oregon Education Service District in Ashland, Oregon. She described herself as an activist and “a provider of gender-affirming healthcare for the past 15 years.” She said that in June 2023, she arranged a letter that was signed by “dozens of folks from the Oregon Pediatric Society” demanding that the AAP pull the conference out of Florida over its LGBTQ-related policies.

In addition to implementing a six-week abortion ban, Florida is among 24 states that since 2021 have passed laws forbidding gender-transition treatment and surgeries for minors; two additional states only ban such surgeries. Against this backdrop, Governor DeSantis and the Republican-dominated Florida legislature have pushed through the legislature a ban on instruction of gender and sexuality in schools; and restricted bathroom access for transgender people. Other legislation erected roadblocks to adult access to gender-transition treatment.

On January 19, Dr. Rafferty, who at least at that time chaired the AAP’s LGBTQ affinity group, relayed via the section’s listserv how the AAP leadership had responded to numerous internal complaints about holding the conference in Florida. “Much concern has been expressed about our group meeting in a state that continues to legally threaten LGBTQ+ people,” he wrote. Saying that the “Executive Committee (EC) members share these concerns,” Dr. Rafferty further referenced the travel advisories that both the NAACP and the LGBTQ advocacy nonprofit the Human Rights Campaign have issued against traveling to the state.

According to Dr. Rafferty, the executive committee had met multiple times to present such concerns to AAP CEO Mark Del Monte – who Dr. Rafferty said, “has committed to continue meeting and working with us.”  

There had been considerable internal discussion among the AAP’s upper ranks about whether to pull out of Florida. At the 2023 AAP leadership conference, held in August in Itasca, Illinois, the executive committee submitted an official resolution to relocate the conference. While the resolution failed, Dr. Rafferty said in his January email that it had “spurred important and thoughtful conversation among AAP leadership.” 

One of the two related resolutions that did prevail saw the AAP, in the resolution’s words, recognizing the “harmful impact of Florida’s discriminatory laws and policies on child health.” Therefore the organization committed to sponsoring programming at the 2024 conference “that empowers pediatricians to address these harmful policies and ensures the safety and well-being of attendees in a threatening and discriminatory environment.” 

A separate resolution – the top such measure to emerge from the 2023 AAP leadership gathering – held “that the Academy advocate for federal protections of gender-affirming care for both patients and their doctors, including payment for medical services” and that the AAP should advocate “for gender-affirming care as a human right.”

According to the former resolution, the conference-related financial implications stood between $1 million and $5 million. (Tax filings indicate that in 2023, the AAP took in $129 million in revenue and had $134 million in expenses.) It further noted that the annual conference’s venue is typically booked 10 to 15 years in advance. Because of the vast associated space demands and the need for 30,000 cumulative nights in hotel rooms, there are just eight to 10 cities that can host this massive event, according to the AAP. (In a more recent release, the AAP indicated that it had secured Orlando as the site of this year’s conference in 2013 and that only 15 facilities in 12 states were large enough to hold the conference.) 

“While we consider advocacy and policy issues carefully,” the resolution stated, “because of the pace of policy change and the conference planning and contracting process, we, like other organizations, are not always able to halt plans in process or predict future changes that will enable meetings to go forward. In other cases, the presence of our meetings and conferences, our members, and the associated media coverage in states and municipalities can have a positive impact on the debate taking place on these important issues.”

Dr. Koutink, for one, was hardly mollified by such overtures. In response to the AAP citing financial barriers when it rebuffed her demand in 2023 to relocate this year’s conference, she in January cynically paraphrased to the LGBTQ listserv the organization’s position by saying that “they ARE fighting for LGBTQ youth and families, but it costs too much money to move the meeting.” She further said: “AAP claims to be the leading advocacy group for equitable health & welfare of children, but in my opinion, this is nothing but empty rhetoric.”

The organization, Dr. Koutnik said, “will support the worst state in the country for the freedom to learn, the freedom to be your authentic self, the freedom of bodily autonomy, and the freedom for physicians to practice high quality patient centered medicine without political interference because Disney World is fun.” 

“It was only in 2016 when the entire country came together to protest the anti-trans bathroom bill in North Carolina,” Dr. Koutnik said, referring to the coalition of powerful businesses that protested a state law passed that year that restricted public restroom and locker room access by biological sex. 

Laura Sinai, a pediatrician in North Carolina, referred in her own email to the LGBTQ listserv to the multiple sports leagues that pulled games out of the state following the bathroom bill’s passage, which helped push the state legislature to repeal the law in 2017. “Money talks,” Dr. Sinai said. “Standing around and pretending to support LGBTQIA in Florida will do nothing.”

By stark contrast, over the past three years, an ever-mounting deluge of LGBTQ-related legislation presented by Republicans in statehouses has been met with diminishing resistance from liberal-minded businesses, which have largely stopped pushing back by withholding, or threatening to withhold, business.

A rueful Dr. Koutnik reflected on the AAP’s own place in this trend, saying to the listserv that “now a few years later our professional organization is spending millions in Florida, proving that the hateful anti-LGBTQ and anti-trans movement has won.” 

Dr. Koutnik and Dr. Sinai were the only members of the listserv named in this reporting who responded to requests for comment. 

“I am disgusted that you’ll be citing my emails,” Dr. Sinai stated over email. 

Dr. Koutnik stated: “As I’m sure you are aware, there is a lot of misinformation, disinformation, and even outright hate around gender nonbinary folks these days.” Presented by the Sun with the excerpts of her emails that would be reported in this article, she wrote: “By citing random quotes from emails out of context that were sent to my friends and colleagues all you have done is prove that you are someone without journalistic integrity.” 

“Publishing advocacy as the standard of care” — critiquing Dr. Rafferty

Part of the AAP’s own battle over the future of pediatric transgender care may be fought in at least one courtroom—if Ms. Ayala, 21, has her way. In October, attorneys from the Texas firm Campbell Miller Payne filed suit against the organization on her behalf. The suit alleges that while Ms. Ayala was in their care, Dr. Rafferty and his mentor at Brown, pediatrician Michelle Forcier, engaged in a conspiracy with the AAP – one that the suit claims directly harmed Ms. Ayala – for him to draft the medical organization’s policy statement on pediatric gender-transition treatment. In particular, the suit argues that the statement, which was published in 2018, violates consumer protection laws by deceiving the public with non-evidence-based claims.

The policy statement has become a cornerstone of the contemporary American approach to caring for gender dysphoric children. Critics say the statement has helped set Americans gender clinics apart from many nations in Europe by observing a particularly liberal approach to prescribing gender-transition treatment. Grounded in what’s known as a gender-affirmative philosophy, the statement instructs care providers to remain deferential to a gender dysphoric child’s perception of their own gender. 

The AAP has remained largely opaque regarding the policy statement in the wake of the lawsuit, which alleges that the document is compromised by a “lack of scientific basis and outright misrepresentations.” The legal complaint refers in particular to a scathing critique of the policy statement that Canadian psychologist and sex researcher James Cantor published in 2019.

Two months after the suit was filed, Mr. Del Monte instructed AAP members who held leadership positions in the organization but who were employed by outside organizations to refrain from using their professional email accounts for AAP business. This directive to use personal email accounts instead—a move that internal AAP documentation indicates was, in fact, planned in early 2023, before Ms. Ayala filed suit—was meant, Mr. Del Monte wrote in a widely disseminated letter, to “protect the internal deliberations of our member experts.” More specifically, the shift would keep outsiders from obtaining internal AAP emails through freedom-of-information requests.  

Among the raft of internal emails subsequently obtained by The Sun through just those sort of public-records requests are communications between Dr. Rafferty and AAP-affiliated colleagues during the period surrounding the publication of the gender-affirming-care policy statement. These documents help shed light on Dr. Rafferty’s principles, background and personal perception of gender-transition treatment’s efficacy as a balm for psychiatric distress. 

The portion of Ms. Ayala’s suit that focuses on Dr. Rafferty and his colleagues caring for her—and ultimately prescribing her testosterone for gender dysphoria—hinges in particular on a March 2017 meeting between the care team, Ms. Ayala, and her parents. Her mother was reluctant to consent to the testosterone prescription. One of the care providers then suggested to the mother that her child would kill herself absent hormonal treatment. The mother subsequently relented. The suit alleges that this suicide-related assertion amounted to non-evidence-based coercion, given the lack of research directly supporting the claim that gender-transition treatment for minors lowers the risk of suicide death.

In an April 2019 email exchange obtained by The Sun, a fellow pediatrician asked Dr. Rafferty about a friend’s depressed trans-identified teenage child who had recently attempted suicide. The doctor asked Dr. Rafferty, “Is there data to support the intuition that gender reaffirming hormones help prevent suicide attempts?” 

Dr. Rafferty’s reply was equivocal. “The perfect study does not yet exist – actually, no population study answers the question of whether hormones are right for any particular person,” he said. “As much as hormones can be ‘life-saving’ in some situations, they also complicate other situations.”

Shown this statement by Dr. Rafferty, Jordan Campbell, an attorney for Ms. Ayala, said: “It is unsurprising to see what Dr. Rafferty appears to acknowledge in his private emails, namely that the science does not support what he advocates for in the policy he authored and implements in his practice. This certainly accords with the allegations and claims, including fraud, we make in Isabelle’s lawsuit.” 

Emails also suggest that Dr. Rafferty was initially educated in a religious-conservative environment, but shed at least one major conservative belief during his medical training. In his January 2024 email to the LGBTQ listserv regarding the AAP’s handling of complaints regarding holding this year’s conference in Florida, Dr. Rafferty expressed his dismay that the state “does not support reproductive rights.”

But he was not always so liberal-minded about abortion. He disclosed this to AAP colleagues in a September 2019 email exchange regarding a medical resident working under the colleague of one of them who did not want “to participate in prescribing” gender-transition treatment to any adolescent patients because of his religious beliefs.

“There is an ethical obligation to rise above prejudice and provide evidence-based (not value-based) care,” Dr. Raffety admonished. “Personally, when I was in medical school, I had a hard time understanding abortion…more because I did not have a lot of personal context and I was coming from a perspective of wanting to be a pediatrician/child advocate (and coming from Catholic high school where a certain perspective was hammered into me).”

As for the question of whether gender-transition treatment is indeed evidenced-based, following the 2018 publication of Dr. Rafferty’s policy statement, new analyses conducted by evidence-based medicine experts have cast a shadow of doubt across the pediatric gender medicine field. Since 2020, a half-dozen systematic literature reviews—the gold standard of scientific evidence—have emerged that have found the research backing pediatric gender-transition treatment wanting and inconclusive. 

Most notably, in April came the publication of the United Kingdom’s Cass Review, a four-year effort that offered withering criticism of pediatric gender-transition treatment as based on “remarkably weak evidence.” In response, the UK promptly joined four Scandinavian nations in sharply restricting pediatric access to gender-transition treatment.

One of the systematic literature reviews on which the Cass Review was partially based characterized the AAP’s policy statement as having especially poor “rigor of development” and “clarity of presentation,” among other shortcomings. 

In tandem with the publication of these scientific reviews, a small group of AAP dissidents, led by the iconoclastic Gresham, Oregon-based pediatrician Julia Mason, has sought to push the organization to re-examine Dr. Rafferty’s policy statement and commission its own systematic literature review. The AAP resisted. In Dr. Mason’s telling, the organization’s leadership continually erected new parliamentary obstacles to ensure that her resolutions were never put up to a vote.

“Every year they come up with new regulations to try to bury my resolutions deeper from the visage of pediatricians,” Dr. Mason said. “It’s Kafkaesque.” 

In August 2022, Moira Szilagyi, then the AAP president, wrote in a blog post for the organization about Dr. Mason’s resolution from that year, saying that “we don’t need a formal resolution to look at the evidence around the care of transgender young people. Evaluating the evidence behind our recommendations, which the unsponsored resolution called for, is a routine part of the Academy’s policy-writing process.” 

With the policy statement coming up for a routine five-year review, the AAP announced in August 2023 it was reaffirming the statement, with no changes. But the organization also stated that it would indeed commission a systematic literature review of pediatric gender transition treatment. However, whereas such reviews are typically structured to be agnostic about their findings, the AAP explicitly indicated that the review’s undertaking was motivated by politics. Pursuing the review, the organization stated, “reflects the board’s concerns about restrictions to access to health care with bans on gender-affirming care.” 

Sarah Palmer, a Carmel, Indiana, pediatrician and AAP member who is among the dissidents who have pushed the organization to conduct such a review, said, “A medical systematic review should be after seeking the best course of treatment for patients, not for the purpose of fighting red state legislators.” She added: “The AAP has not said a word about the status of the systematic review.” 

Indeed, There is no evidence that the AAP has yet followed standard protocol by publishing the review’s methodology.

University of Oxford sociologist Michael Biggs told the Sun: “After a year, we would expect to hear how this review is proceeding.”

Dr. Palmer said of her and Dr. Mason’s continued efforts to pressure the AAP: “Our resolution this year asked for transparency in the review process. The resolution was unsponsored and ignored.” 

On Tuesday, Dr. Mason said on social media regarding the AAP’s leadership: “I was really hoping a year ago when they said they were going to do a systematic review of the evidence, that they would use that as a pathway out of this madness.”

Such dissident pediatricians now have powerful company in the effort to pressure, if not outright force, the AAP toward greater transparency. On Tuesday, a group of 20 Republican attorneys general, led by Idaho’s Raúl R. Labrador submitted a letter to the AAP requesting responses to a series of probing questions that suggested that the organization may have violated state consumer protection laws by claiming—falsely, the letter asserts—that puberty blockers are “reversible.”

“That claim is misleading and deceptive and requires immediate retraction and correction,” the letter states.

This isn’t the first time a state attorney general has sought internal documents from medical groups that are leaders in the pediatric gender medicine field. In June, a federal judge unsealed a trove of internal emails from Wpath, the influential medical-activist group largely based in the United States, that was subpoenaed by Alabama’s attorney general. 

These documents revealed that in 2022, Rachel Levine, the Biden administration health official, had pressured Wpath – for explicitly political purposes – to remove from its forthcoming revision of its influential transgender-care guidelines all age restrictions on gender-transition treatment. Then, shortly before WPATH published the new guidelines in the fall of that year, an AAP representative threatened Wpath that if it did not remove the age restrictions, the AAP would not only not endorse the guidelines, it would come out publicly against them. Wpath promptly acceded to this demand, and did so without engaging in its standard scientific process for reaching internal consensus, the subpoenaed documents demonstrate.

In public, the AAP continues to maintain that pediatric gender-transition treatment is grounded in sound science. In a September “advocacy report”, the organization called attention to the upcoming oral arguments at the Supreme Court case over Tennessee’s ban of pediatric gender-transition treatment. The organization noted that it had submitted an amicus brief to the court that contained “information pertaining to the established, evidence-based standards of care as developed by the World Transgender Health Organization (Wpath) and the Endocrine Society for the treatment on transgender and gender-diverse youth.”

Leor Sapir, who studies pediatric gender medicine at the Manhattan Institute, said, “As with most of what the AAP has said on this issue, its statements seem plausible until you look carefully and scientifically at the evidence they cite.” Referring to a quote from one of the Wpath emails subpoenaed by the Alabama attorney general, he said, “Even WPATH leadership has said that the AAP’s recommendations ‘have a very weak methodology, [and were] written by [a] few friends who think the same.’”

The longtime AAP member from Northern California told the Sun that the AAP “seems to be willfully overlooking the lack of evidence for these quite dramatic medical interventions on the bodies of young people, many of whom are quite vulnerable. That they can continue to uphold this position, despite the policy shifts in other countries around the world who have actually examined the evidence, and in the face of mounting demonstrable harm to our patients, just seems unconscionable to me.”

Doriane Lambelet Coleman, a Duke Law professor and the author of On Sex And Gender: A Commonsense Approach, argued in an interview that pediatric gender medicine is not the only domain in which the AAP has favored what she characterized as advocacy over an evidence-based approach to thorny ethical issues. This has included, Ms. Coleman said, the AAP’s policy statements regarding sibling organ transplants and what’s known as the mature minor rule, in which an unemancipated minor may be deemed mature enough to make general medical decisions.

“They have a decades-long history of publishing advocacy as standard of care,” Ms. Coleman said of the AAP. “The fact of them being a political organization is not a new phenomenon at all.” 

Among the members of the AAP committee that edited Dr. Rafferty’s 2018 policy statement was Michael Yogman, a now-retired Cambridge, Massachusetts, pediatrician. Asked about Dr. Rafferty’s policy statement, Dr. Yogman said in an email that he thought the document was “excellent” and noted that it “went through extensive AAP review before publication.” But he further stated: “The issues around gender affirming care are not in my area of expertise and I have not closely followed the debate and controversy within the AAP.”

Asked how he could be certain of the policy statement’s quality given his lack of expertise in the field, and also asked whether he had read Dr. Cantor’s critique, Dr. Yogman did not directly reply. Instead, he further stated that he had “not followed subsequent comment by James Cantor or others and will defer to Dr. Rafferty’s response since he authored the paper.”

According to Dr. Cantor, neither the AAP nor Dr. Rafferty has ever responded to his criticisms about the policy statement.

Neither the AAP’s spokespeople, nor Dr. Rafferty, nor representatives for Dr. Levine responded to multiple requests for comment from the Sun. However, two days after this reporter submitted his initial request for comment, an AAP spokesperson wrote to tell him his request for a press credential to cover the Orlando conference, submitted in July, had been denied.

A culture of secrecy and silence

Multiple pediatricians who spoke with the Sun depicted a repressive, sweeping silence across their field regarding any skepticism about the gender-affirming care method. This included what they said was institutionalized resistance by the AAP to the standard scientific process of scrutinizing and debating research findings and emerging clinical practices in the care and treatment of gender dysphoric minors. Some doctors reported being too afraid to raise questions among pediatric colleagues for fear this would damage their careers. 

“There is a culture in the AAP of secrecy about the development of Rafferty’s statement, and now about the systematic review,” Dr. Palmer said in an email. “The AAP does good work in many areas, but the leadership has harmed its credibility by stubbornly clinging to a simplistic understanding of gender care (the affirmation-only model).” 

Another pediatrician who requested to remain anonymous for fear of just the sort of reprisals she described, said that “another powerful deterrent” to declaring skepticism regarding pediatric gender-transition treatment “is the fear of intense emotional backlash from pro-gender-affirming colleagues. I’ve been on the receiving end of that a couple of times at my institution, from people I otherwise consider friends.”

This doctor argued that an absence of open debate within the AAP on this subject has left many of her fellow pediatricians in the dark about the granular specifics of pediatric gender medicine and the associated weak and uncertain evidence base. 

At last year’s AAP conference, held in Washington, DC, the organization did, however, allow the Foundation Against Intolerance & Racism, or FAIR, to hold a booth. The nonprofit, which holds a skeptical view toward pediatric gender medicine given the current evidence base, hosted five detransitioners as well as Jamie Reed, the whistleblower from Washington University in St. Louis’ pediatric gender clinic, who has emerged as a major activist opposing such medical interventions. 

In interviews, Ms. Reed and several other members of the group that staffed the booth for FAIR characterized their interactions with conference attendees as largely respectful. Many pediatricians, they said, expressed surprise and concern when told of the shakiness of the science behind pediatric gender-transition treatment and the harm that the detransitioners reported they had sustained from such interventions.

The Northern Californian AAP member attended the conference and said that she closely observed the FAIR booth. There, she said, “I did see a couple somewhat more heated exchanges, but these were initiated by people passing by, not those who were at the booth.”

Multiple members of FAIR’s group did report that one exchange in particular, between an unidentified AAP member and a few of the booth’s attendants, became especially heated after the pediatrician was particularly critical of one of the detransitioners, Camille Kiefel, to her face and caused her to cry.  

In March, the Daily Caller reported, based on emails it obtained through its own public-records request, that Gina Sequeira, co-director of the Seattle Children’s Gender Clinic, wrote to AAP leadership the day after the 2023 conference had completed, reporting that there was “verbal harassment experienced by one of our trans-identified members” at FAIR’s booth. Dr. Sequeira stated that multiple members of the AAP who were LGBTQ or provided gender-affirming care to children had asserted that FAIR’s presence had made them “lose trust in the AAP” and doubt whether the conference could be a “safe space for them in the future.” 

Dr. Sequeira further wrote that, at the conference, “we escalated some of these concerns to Mark”—presumably Mr. Del Monte—“and he provided us with verbal reassurance that something like this wouldn’t happen again.” But she thought a formal response was necessary “given the degree of harm” caused by allowing FAIR to hold a booth.

“What harm exactly are they talking about?” the Northern Californian AAP member said to the Sun via email. “Harm to their feelings, their reputation, their world view? And where’s the concern for the actual physical harm being done to our young patients?  This seems like self-serving blather to me.”

In a January 2024 email from the AAP’s LGBTQ listserv that was obtained by the Sun, pediatrician Laura Sinai expressed anger and disappointment over the AAP allowing FAIR to attend the conference in the first place. “I don’t believe it was an accident,” Dr. Sinai wrote. “I don’t think they cared. And the AAP did nothing about FAIR the whole time they were there despite many complaints to let them know. Despicable and horrible.”

On the same email thread, Philadelphia pediatrician Kate Hentschel recounted to listserv about having been “harassed” by the FAIR group at the 2023 conference. “I personally do not feel safe going to Florida as a visibly queer/genderqueer human,” Dr. Hentschel said. FAIR’s presence that year, the pediatrician said, “solidified my decision” not to attend in the fall.

None of the FAIR representatives interviewed said they recognized Dr. Hentschel based on the physician’s headshot. In an interview, Ms. Kiefel suggested that some of the devoted advocates of the gender-affirming care method may have misperceived their interactions with the FAIR booth as hostile. “If you talk to somebody and your personal beliefs are challenged, it feels like you’re being attacked,” said Ms. Kiefel.  

Cincinnati, Ohio-area pediatrician Christopher Bolling stated in a January 19 email to the LGBTQ listserv, “As for FAIR, they got in somehow, but were effectively prevented from getting into presentations with a [sic] exhibitors’ badge. Security responded quickly and effectively in the session they targeted. I believe the whole episode has triggered a completely new vetting process for exhibitors.”

The following month, FAIR’s director, Monica Harris, received a letter from the AAP rejecting their application to attend the 2024 conference in Orlando. It stated that the “AAP is exercising its right to decline your organization’s request to exhibit,” but did not provide a specific reason.

Similarly, the AAP blocked the Society for Evidence Based Gender Medicine from holding a booth at the pediatric group’s 2021 conference, prompting a headling by writer Abigail Shrier for The Wall Street Journal: “A Pediatric Association Stifles Debate on Gender Dysphoria.” SEGM is a network of skeptics of pediatric gender medicine, including founding member Dr. Mason, who scrutinize the field based on evidence-based medicine principles. 

In an August 2021 email obtained by the Sun that was forwarded to a listserv for AAP members in western North America, Andrew Cronyn, a pediatrician at Transhealth Northampton in Massachusetts, provided a link to an article written by a British trans activist, Mallory Moore. In the article, she condemned SEGM as an “anti-trans psychiatric and sociological think tank” pushing “dodgy science.”

“It’s important that we know about these groups and fight them at every turn,” Dr. Cronyn wrote to his pediatric colleagues. 

Ms. Moore was later one of the primary sources of misinformation about the British Cass Review in the immediate wake of its publication in April. 

Patrick Hunter is a pediatrician in Pensacola, Florida, and a major bête noire of trans activists such as Ms. Moore, given he sits on the Florida Board of Medicine that in 2022 voted to adopt a state rule that banned pediatric gender-transition treatment and surgeries. He was also a member of the FAIR team at last year’s confab.  Speaking in his personal capacity and not representing the state board, Dr. Hunter, told the Sun that he proposed a panel discussion with detransitioners for the Orlando AAP conference. The AAP rejected his application.

Asked for his reaction to the AAP’s rejection and its decision to invite Rachel Levine to give a keynote address at the conference, Dr. Hunter said: “It communicates to me that they’re probably beholden to a small minority of the membership and to a sociopolitical agenda. They’re beholden to diversity, equity and inclusion and not the well-being and good of the patient.”

Dr. Hunter did, however, assemble a panel of seven detransitioners at the Catholic Medical Association meeting Orlando on September 5, in what was billed as the first panel of its kind at a U.S. medical convention.

The convention finally convenes

Katherine Welch, is a Carmel, Indiana, pediatrician who told the Sun that she left the AAP in part because of its unwavering support of pediatric gender-transition treatment. Making what she acknowledged was a hyperbolic reference to Governor DeSantis’ tug-of-war with Disney over the company’s opposition to his LGBTQ-related policies, she wrote in an email, “Even though the conference is in Florida, that will be buffered by the fact that it is held at Disney Resorts, a kind of ‘rainbow oasis’ in a ‘desert of hate’ and wanting to keep Disney alive.” 

The AAP leadership has telegraphed to members its ambivalence over establishing its own temporary island of pediatricians within DeSantis country for the coming five days of the conference. 

“We know Florida has made several unfortunate decisions the last few years, and the pediatricians have been here fighting for children’s and women’s rights,” Florida AAP chapter president Thresia B. Gambon said in an April release. But, in reference to the state’s AAP members as a whole, she said, “We want to continue to be here to represent, to try to educate our legislators to make better decisions and hopefully improve care in our state.”

As a 501(c)3 nonprofit, the AAP is barred from political campaigning. 

Back in January, Dr. Hentschel said in an email to the LGBTQ listserv that the AAP should meet a litany of demands over the Florida conference, including “significant gender-affirming LGBTQ focused content,” given the Philadelphia pediatrician’s disappointment over a paucity of such content at the 2023 meeting. Dr. Hentschel also sought “more security and oversight to prevent transphobes, bigots, and possibly armed vigilantes from infiltrating the conference.” 

To address such safety concerns, the AAP put out a detailed “safety and inclusion” statement in May on the security measures it is taking to protect conference goers. This included an assertion that the “City of Orlando has received a perfect score from the Human Rights Campaign’s Municipal Equality Index.”

On August 15, the AAP published an impassioned YouTube video entitled “Hear from our Florida Members” that entreated pediatricians to attend the Florida meeting to support their fellow members working on the ground. But according to the internet archive of the page, by September 5 the organization had reverted the video to an unlisted status and swapped in a different, 20-second video that more generically advertised the conference and lacked the voices of the local pediatricians.

Then, in a September 19 newsletter detailing the upcoming convention, the AAP highlighted, albeit at the very end of a long roster of items, a link to a short list of Florida charities – a “SocialOffset campaign” – to which members could donate that are “committed to equity, service.” This included one organization supporting LGBTQ+ youth. 

As for LGBTQ programming for general conference goers, the AAP’s offerings are actually quite sparse. The online conference program has 421 entries, only two of which include the term “LGBTQ” and one of which includes the word “transgender.” Between them, this includes one session on promoting physical activity participation and inclusion in transgender youth; another on the “Top 10 Articles Promoting LGBTQ+ Health and Wellness”; and a third on “Continuity, Competency, and Compassion for LGBTQ+ Patients and Families.”

In a detailed press packet broadcast to science journalists in advance of the conference, there was no explicit mention of gender or LGBTQ issues.

The LGBTQ affinity group, however, will hold its own invite- and section-members-only, five-and-a-half hour program at the conference on Monday afternoon, entitled “Celebrating Lessons from LGBTQ+ Community Champions: Resilience during Crisis.” The AAP has taken considerable steps to shield this gathering from the public eye, including requiring a password to access the agenda and a photo ID for entry to the event; forbidding attendees from taking recordings of the program and requiring they to shut down all electronic devices on site (“unless medically or absolutely necessary”); and requesting that those who are registered “not share attendance or content from the section program.”

The program, which the Sun obtained through a public-records request, doesn’t even list the names of the three main speakers. Instead, it notes, for example, that a “Southern Legal Counsel” will provide an “Update on the Legal Landscape of LGBTQ+ Health Care.” The AAP won’t inform attendees of the event’s location until Sunday. 

For the conference overall, the AAP admonished attendees via email in August not to share password-protected information from the organization with outside sources. “This protects our work together and allows the rich, dynamic and candid collaboration between colleagues to continue,” wrote Mr. Del Monte in a recent directive. The conference code of conduct also forbids attendees from taking video and screenshots of presentations without written permission.  

Most coveted by outsiders will be details about Sunday afternoon’s keynote speech by Rachel Levine. Outside of the imbroglio over her 2022 pressure campaign on WPATH over its trans-care guidelines, Dr. Levine has sustained considerable recent criticism from skeptics of gender-transition treatment for claiming that such medical interventions are “life saving” despite a lack of scientific evidence to support this claim. 

Dr. Levine is, however, expected to receive a warm reception from the AAP rank-and-file. 

“She is an accomplished pediatrician and service member,” Thomas Ngyuen, a pediatrician from Canton, Ohio, told the Sun. “Based on her experience on contributions to our specialty she is obviously qualified for this honor.”

The meeting will also be met by protesters, arranged in part by Ms. Reed, who are opposed to the AAP’s policies on pediatric gender medicine.

Asked to respond to the AAP’s decision to make Dr. Levine the centerpiece of the conference, Ms. Reed said of the organization’s leadership: “They’ve dug in.”

Saying she expected the field of pediatric medicine to crumble in the coming years, Ms. Reed added: “And I feel like they’re going to let the AAP go down with the ship.”