The claim that “gender-affirming care” (GAC) for gender nonconforming youth is universally supported by major medical organizations often rests on three key documents: the American Academy of Pediatrics’ (AAP) 2018 policy statement, the Endocrine Society’s 2017 guideline, and the World Professional Association for Transgender Health’s (WPATH) Standards of Care (SoC). These form a powerful trifecta, frequently cited to assert a scientific consensus on treatments like puberty blockers and hormones. However, their reliance on circular referencing—each citing the others without robust evidence—undermines their credibility. This article examines the trifecta’s flaws, the risks of this cycle, and the need for evidence-based reform.
Exposing the Circular Referencing Loop
The AAP’s 2018 policy, authored by Jason Rafferty, champions an affirmation-only model, advocating puberty blockers and hormones by citing WPATH’s SoC7 and the Endocrine Society’s 2017 guideline. The Endocrine Society recommends hormones, referencing WPATH’s SoC, while admitting its evidence is “low” quality. WPATH’s SoC7 and SoC8, in turn, lean on the AAP and Endocrine Society, relying heavily on a flawed Dutch study criticized for bias and short follow-up. A 2021 study scored WPATH’s SoC7 a zero out of six for rigor. This circular loop—AAP citing WPATH and Endocrine Society, WPATH citing AAP and Endocrine Society, and Endocrine Society echoing WPATH—creates a false consensus, amplifying unproven claims without independent evidence.
Flaws in the Trifecta’s Evidence Base
Critiques reveal significant weaknesses in the trifecta. James Cantor’s 2018 analysis found the AAP misrepresents sources, conflating sexual orientation conversion therapy with exploratory psychotherapy and ignoring studies showing 61–98% of gender-dysphoric youth desist by puberty, often identifying as gay or lesbian. Michael Biggs’ 2022 work criticized the AAP’s claim that puberty blockers are reversible, noting 96–100% of youth progress to hormones, risking infertility and bone density loss. Kathleen McDeavitt’s 2025 critique exposed the AAP’s mental health benefit claims as resting on one study with small, questionable improvements, while other cited sources lack relevant data. The Endocrine Society sidesteps whether hormones should be used, and WPATH’s reliance on the Dutch study is inapplicable to today’s population of adolescents self-identifying as transgender.
Risks and the Path to Reform
The trifecta’s circular referencing raises concerns about misdiagnosis, particularly for youth whose gender distress may reflect emerging gay, lesbian, or bisexual identities. Lawsuits from detransitioners highlight rushed treatments without proper mental health screening. Unlike Sweden, Finland, and the UK, which prioritized psychotherapy after systematic reviews found inconclusive evidence for medicalization’s benefits, U.S. organizations lag, ignoring calls for such reviews. A 2025 U.S. Department of Health and Human Services report echoed these findings. To protect gender nonconforming youth, the AAP and Endocrine Society must retire their guidelines and commission new ones based on rigorous, independent research, free from ideological bias, ensuring compassionate, evidence-based care.