Thread by @writingblock

Last year, @AmerAcadPeds told me its 2018 policy statement on gender-affirming care–while not based on a traditional systematic review of the evidence–was based on “rigorous evidence review.” Now AAP has announced it will commission a systematic review. bmj.com/content/382/bm…

Typically, in evidence-based medicine, strong recommendations follow systematic reviews finding high quality evidence that the treatments in question improve patient outcomes, says @GuyattGH. Existing reviews have found "low quality" evidence. Still, AAP reaffirmed its policy.

Sweden, Finland, & England have restricted treatments in minors. Norway’s Health Care Investigation Board (Ukom) recently recommended updated national guidelines based on systematic reviews, calling hormonal treatments in under 18YOs investigational. bmj.com/content/380/bm…

The 2018 @AmerAcadPeds policy directs that "many medical interventions can be offered to youth who identify as transgender and gender diverse," including social affirmation, blocking hormones, cross-sex hormones, and on a case-by-case basis, surgeries. publications.aap.org/pediatrics/art…

Systematic reviews are transparent: which studies included, how they're graded. AAP's process for reviewing the evidence base for its 2018 statement is not. This peer-reviewed article finds several points of incoherence between statements and citations: ohchr.org/sites/default/…

Meanwhile, AAP's statement tells providers there is only one acceptable approach--affirmation. The historic Dutch approach of "watchful waiting" to see how a young patient's identity develops is "outdated" and "does not serve the child because critical support is withheld."

The @AmerAcadPeds 2018 statement tells docs, nurses, therapists that even before the onset of puberty, kids who identify as trans or gender diverse "know their gender as clearly and as consistently as their developmentally equivalent [cisgender] peers."

This is key: in gender care, no blood test or brain scan tells a doc their patient has a condition requiring treatment. They can check the boxes that define dysphoria, but the 2018 AAP statement also makes clear trans and gender diverse IDs "do not constitute a mental disorder."

As the 2018 @AmerAcadPeds statement's lead author Jason Rafferty told me, in gender-affirming care, a "child's sense of reality" is the "navigational beacon to orient treatment around."

It’s impossible to measure the impact of the @AmerAcadPeds 2018 statement on gender care, but in the story of how the U.S. medical establishment came to "consensus" that kids' sense of self should determine medical treatment, it will be a key chapter. bmj.com/content/382/bm…