The public often assumes that medical societies act in the best interest of patients and the broader society. In reality, however, these organisations make decisions not based on official medical guidelines but under the influence of professional interest groups. Driven by various incentive systems, doctors have developed a financial stake in performing gender transition surgeries — and in some cases, they prioritise their own interests even when treating children.

The Department of Health and Human Services’ new report on best practices for treating pediatric gender dysphoria provides a dispassionate analysis of an extraordinarily complex issue. Its overview of 17 systematic reviews — the highest standard of medical evidence — arguably offers the most comprehensive analysis of pediatric medical transition to date, the City Journal writes.

Yet, just a few hours after the release of this 409-page report on May 1, the American Academy of Pediatrics (AAP) issued a press release condemning it for relying on a “narrow set of data and perspectives” and for “misrepresent[ing] the current medical consensus and fail[ing] to reflect the realities of pediatric care,” among other alleged faults.

The AAP’s „knee-jerk” response — and its continued endorsement of gender medicine in the face of low-quality evidence — only serve to strengthen the HHS report’s specific findings that medical societies like the AAP have played a major role in the ongoing scandal of the treatment of pediatric gender-transition in the U.S.

Doctors Have a Vested Interest in Performing Gender Transition Surgeries

As the HHS report notes, the public tends to assume that medical associations “prioritize the best interest of patients and society.” In practice, however, these organizations function as trade groups, not as official arbiters of medical standards. While many individual members have their patients’ best interests at heart, the associations themselves often follow incentives aligned with their members’ professional interests — ones that can lead even the most well-intentioned doctors astray.

This dynamic is especially visible in the field of gender medicine.

Since pediatric gender medicine is relatively new, medical associations frequently defer to ideologically insular subcommittees on LGBT issues when crafting treatment recommendations. The problem, the HHS report argues is that these subcommittees tend to be echo chambers where “dissent is suppressed” and “confirmation biases go unchecked.”

Specialists on these subcommittees also often have conflicts of interest that make them less open to alternative perspectives. These conflicts of interest can be intellectual, as when specialists endorse “affirming care” as a matter of human rights, or financial, as when their livelihoods depend on providing sex-rejecting interventions.

A shift away from the affirming-care model would directly threaten their livelihood—now a multibillion-dollar industry.

These incentive structures help explain how the AAP ended up issuing a 2018 position statement endorsing “affirming care” that was conceptualized, drafted, reviewed, and revised by a single junior pediatrician, Jason Rafferty, a relatively new physician not high up within the AAP hierarchy.

The AAP’s 2018 statement politicized the treatment of sex-related distress, framing it as a civil rights issue rather than a medical one.

The AAP’s rubber-stamping of the ideological reframing of sex-related distress has had serious consequences for patients.

The American Academy of Pediatrics has continued to endorse gender medicine in the face of low-quality evidence—which only strengthens the HHS report’s findings that medical societies have played a major role in the treatment of pediatric gender-transition in the U.S. pic.twitter.com/z9ZqLXve7A

— City Journal (@CityJournal) May 16, 2025

Both Rafferty and the AAP are named as defendants in a medical-negligence lawsuit filed by Isabelle Ayala, a detransitioner who alleges that she was approved for testosterone therapy at age 14 after a single, hour-long assessment—despite a history of complex psychiatric issues and sexual assault. Rafferty is also a defendant in a separate lawsuit brought by another detransitioner, Layton Ulery. That suit accuses the AAP of civil conspiracy, fraud, and medical malpractice, charging that the organization’s ideological approach to gender medicine resulted in iatrogenic harm — that is, harm caused by the medical procedures themselves.

Despite this, in 2023 the AAP reaffirmed its 2018 position statement without an evidence review, even as the U.K., Finland, and Sweden were formally reviewing and updating their treatment practices for sex distress. Though it promised an evidence review in 2023, the AAP has yet to release one.

Professional Organizations Legitimize Their Own Regulations, While Ignoring Medical Ethics

Along with the AAP, the World Professional Association for Transgender Health (WPATH) and the Endocrine Society have played the largest role in informally regulating gender medicine in the U.S. As the HHS report argues, these organizations endorse “affirming care” in their treatment guidelines despite low-quality evidence. In turn, other medical associations uncritically adopt their guidelines, choosing to defer to their ostensible expertise.

WPATH did eventually commission researchers at Johns Hopkins to conduct systematic reviews on pediatric gender medicine. However, it reportedly suppressed these reviews when the findings failed to support its predetermined commitment to expanding access to medical interventions.

Sweden, Finland, and the U.K. have already changed course on pediatric gender medicine. Given the less centralized nature of health care in the United States, medical societies like the AAP have an even greater responsibility to be transparent about the quality of the evidence informing their recommendations.