A handful of pediatricians who perform sex-change procedures on children led a successful pressure campaign to push a major transgender medical organization to remove age minimums for life-altering sex-change surgeries from its clinical guidance, according to emails exclusively obtained by the Daily Caller News Foundation.
Emails reveal the American Academy of Pediatrics (AAP) asked just four doctors — all of whom are considered leaders in the field of pediatric sex changes and have performed various transgender procedures — to review and provide feedback on an embargoed copy of the World Professional Association of Transgender Health’s (WPATH) clinical guidance, called the Standards of Care version 8 (SOC-8), weeks before its expected publication.
Based on the four doctors’ review, the AAP strong-armed WPATH into removing sex-change surgery age minimums from the SOC-8.
When the AAP asked the four pediatricians —Jason Rafferty, Ilana Sherer, Juanita Hodax, and Brittany Allen — to review the SOC-8 on the organization’s behalf in 2022, Rafferty, Sherer, and Allen were on the leadership team of the AAP’s Section on LGBT Health and Wellness, a group within the AAP that provides the organization with expertise and education on LGBT issues, according to an archive of its website.
The Biden-Harris administration also pressured WPATH to remove sex-change surgery age limits from their clinical guidance, according to records made public by Alabama Attorney General Steve Marshall while defending Alabama’s law restricting pediatric sex-change procedures.
In an amicus brief submitted in the upcoming Supreme Court case United States v. Skrmetti, Marshall explains that Department of Health and Human Services (HHS) Assistant Secretary for Health Rachel Levine — who is openly transgender — had unsuccessfully pressured WPATH to remove the surgical age minimums, but the pressure from the AAP “tipped the scales,” causing WPATH to remove the child sex-change surgery age minimums.
“Thanks to the Biden Administration and AAP, SOC-8 does not contain age minimums for any transitioning hormonal or surgical intervention except for one: phalloplasty, the surgical creation of a neopenis,” reads Marshall’s brief. “WPATH considers all other surgeries and interventions ‘medically necessary gender-affirming medical treatment[s] in adolescents.’”
Tipping The Scales
In August 2022, after securing an embargoed copy of WPATH’s clinical guidance, AAP state government affairs analyst Jeff Hudson asked the pediatricians to review how the guidance aligned with current AAP policy. Rafferty was the lead author of the AAP’s controversial child sex-change policy, first published in 2018, that supported the use of puberty blockers, cross-sex hormones and sex-change surgeries for minors. Reaffirmed in 2023, the AAP’s transgender policy notably excluded age minimums for drug or surgical interventions.
Hudson stressed the importance of reviewing the SOC-8 before it’s publication, noting it would have “implications” for their “existing legal arguments” as they fought state bans on child sex-change interventions in court.
“I explained our position and reasoning behind securing access to SOC-8 before its publication and WPATH agreed that the AAP and AAP chapters are leading the fight to protect access to this care at the state level and needs to be as prepared as possible,” wrote Hudson.
“There are implications for our existing legal arguments that I’ll work through with our counsel once you’ve reviewed and provided feedback.”
Hudson requested the feedback quickly so that the AAP would have time to “formulate an advocacy strategy and media strategy” before the SOC-8’s anticipated release in September. Emails show a small group from the AAP, which included Hudson, the gender pediatricians and CEO Mark Del Monte, was given access to the embargoed guidance.
The DCNF obtained a series of heavily redacted emails that appear to be discussions in which the gender pediatricians reviewed and commented on the embargoed draft of the SOC-8. In one heavily redacted email, Rafferty alluded to differences between the AAP’s policy and the WPATH clinical guidance, writing: “I personally continue to support the AAP’s current position over WPATH in my practice as articulated in the statement.”
Hudson met with WPATH leadership on Sept. 5, 2022, and the following day reached out to Sherer, Rafferty, Hodax, and Allen, sending an attachment with their final “collated” comments on the SOC-8, promising to touch base with them all about “the plan moving forward.”
On Sept. 8, 2022, then-AAP president Moira Szilagyi sent a letter to WPATH letting them know the final version of the SOC-8 “raised concerns” from their clinical experts, who emails revealed to be Rafferty, Sherer, Hodax, and Allen. The AAP specifically took issue with WPATH’s inclusion of age minimums for pediatric sex-change surgery and their validation of “anti-transgender arguments.”
“AAP experts agree SOC8 lacks the evidence to justify the recommended surgery ages,” Szilagyi wrote, ending with a request that AAP subject-matter experts meet with WPATH for further discussion.
Neither Sherer, Hodax, nor Allen responded to the DCNF’s multiple requests for comment.
‘Very Junior People’
Documents released by AG Marshall detail how the AAP’s refusal to endorse the SOC-8 sent WPATH into chaos.
In response to the AAP’s letter, Scott Leibowitz, a co-lead of the SOC-8 chapter on adolescents, urgently created a task force to review the AAP’s feedback and “figure out next steps,” according to an email sent Friday, Sept. 9, 2022.
“The American Academy of Pediatrics (AAP)- a MAJOR organization in the United States that is typically very pro-transhealth/gender affirming care- voiced its opposition to the SOC8, specifically due to aspects of the Adolescent chapter. Not only did they say they would not endorse the SOC, they indicated that they would actively publicly oppose it,” wrote Leibowitz.
“Clearly, if AAP were to publicly oppose the SOC-8, it would be a major challenge for WPATH, SOC-8, and trans youth access to care in the U.S.,” Leibowitz wrote.
That same day, Jon Arcelus, one of three co-chair’s responsible for leading WPATH’s SOC-8 development team, wrote to colleagues that he did not agree with bending the knee to the AAP’s request to remove sex-change surgery age minimums. In an email, he referred to the AAP’s policy as a “one sided narrative” and said making the changes they demanded “will make a joke of our methodology” and look “weak.”
“We can’t not [sic] write a document that looks like theirs, as it has a one sided narrative, extremely biased. I will be surprised in their guidelines are used at all,” wrote Arcelus.
“I think it will not be in the benefit of our community to remove ages as an suggestion and to make any of the changes that they are recommending. This will make a joke of our methodology and will see us as weak,” he wrote.
Then-president of WPATH Walter Bouman responded to Arcelus, writing: “I have also read all the comments from the AAP and struggle to find any sound evidence-based argument(s) underpinning these. I am seriously surprised that a ‘reputable’ association as the AAP is so thin on scientific evidence.”
Arcelus wrote he was “shocked” that the comments about the SOC-8 had come from “very junior people at the AAP.”
“I was shocked to see the feedback from very junior people from AAP, my suggestion was not to make any changes,” wrote Arcelus.
Leibowitz declined to comment through a Nationwide Children’s Hospital spokesperson. Neither WPATH, Arcelus, nor Bouman responded to the DCNF’s multiple requests for comment.
‘Reached A Deal’
In the early hours of Sept. 10, 2022, Arcelus sent WPATH colleagues his comments on the AAP’s requests to change the SOC-8.
“I am including the pdf with the comments from AAP. I have gone one by one through them and add my comments […] as to why we are not going to make changes or if we are say that we are removing it,” wrote Arcelus.
“Time is a problem as we want the SOC-8 to be out for Montreal, so we need to agree tomorrow whether 1) we ignore all their comments 2) we remove the sections that I suggest or more if you feel,” Arcelus wrote.
WPATH was under pressure to resolve the dispute with the AAP quickly, as it wanted to release the SOC-8 before an upcoming scientific symposium that began Sept. 15, 2022, in Montreal, Canada.
Through a public records request, the DCNF obtained 30 hours of recordings from the private WPATH symposium, where several speakers noted the SOC-8 was published the night before the symposium began.
Around midday on Sept. 10, 2022, Arcelus sent Hudson an email titled “Last version with changes.” The email included an attachment titled “SOC8 Final edit as agreed with adolescent chapter,” informing Hudson that WPATH had removed the age minimums from the SOC-8 as “agreed” upon and asking for the AAP’s endorsement.
“Thank you very much for today’s meeting and the support through this process. We have just finished our meeting and we have agreed to remove the ages and to add the sentence we agreed,” wrote Arcelus. “I hope that by doing this AAP will be able to endorse the SOC8 or at least to support it.”
Hudson forwarded the email to Rafferty, Sherer, Allen, Hodax and Mark Del Monte, asking: “Do you approve of these changes?”
“I think these changes are sufficient so that we would not need to oppose SOC8,” Rafferty responded, adding he didn’t see anything that “explicitly or directly contradicts or opposes our policies.”
“For us all, I think it is important to recognize that the [policy statement] is still our official policy even after SOC8 is released. These changes allow SOC8, especially the recommendations themselves, to at least be aligned with the [policy statement] without anything that explicitly or directly contradicts or opposes our policies,” wrote Rafferty.
Later that afternoon, Eli Coleman reported to his colleagues that the AAP was “satisfied with the proposed changes” and that the group was ready to provide a statement in support of WPATH.
One person on the WPATH email chain, whose name was redacted, wrote: “May I thank each and all of you for the tremendous effort you made to reach a deal with the AAP and to allow the SOC 8 to be published.”
‘So Much More’
Rafferty played a critical role in the development of the AAP’s child sex-change policy, which has no age minimums for sex-change surgery and refers to puberty blockers as “reversible treatments.”
The DCNF obtained an email written by Rafferty in June 2022 responding to a series of questions from the powerful D.C.-based Covington and Burling law firm, which represents the AAP in litigation seeking to overturn Alabama’s ban on pediatric sex-change, about the appropriateness of pediatric sex-change.
“We recently reviewed a lengthy article in the New York Times Magazine entitled ‘The Battle Over Gender Therapy’ […]. Given the prominence of the NY Times and the tenor of the article, which raises many questions about the appropriateness of gender-affirming care, we expect the article may be cited in support of bans on gender affirming care,” the law firm wrote. “Below we’ve listed some points from the article which may be used to support such bans or to challenge our amicus briefs, and some questions from our team.”
Despite the AAP’s push to remove age minimums from the WPATH SOC-8, Rafferty, when referring to gender exploration, told the law firm that some youth “try it out” without needing intervention.
“Do some youth ‘try it out’ – Yes, as children grow up gender exploration is a NORMAL part of development and understanding the society roles [sic] around them. Exploring one’s gender does not mean that any intervention is necessary aside from support and assuring their safety,” wrote Rafferty.
Unmentioned Risks
In his response to the law firm’s questions, Rafferty described how puberty blockers can cause sterility in children and admitted there were no studies evaluating whether puberty suppression leads to sexual dysfunction.
“Long story short, if you start blockers early in puberty before the eggs or cells that give rise to sperm mature (essentially before someone starts to menstruate or ejaculate), then later go directly on directly to cross sex hormone, then you never allow the maturation to occur and will essentially be sterile,” wrote Rafferty.
Rafferty further explained that while patients who’ve received sex-change interventions may have physical limitations in the mechanics of sexual intercourse, the experience of being sexually intimate in their “chosen” sex was “worth so much more to them.”
“Sexual dysfunction: As far as I know there is no study that looks at this, and frankly it would be a difficult study to do,” wrote Rafferty.
“The mechanics of an ‘internal orgasm’ and pleasure are quite different than penile erection, climax, and release of semen,” Rafferty wrote. “A fundamental point, however, is that for many people who are trans female, penile stimulation and external orgasm may actually be quite dysphoric and lead to an aversion or avoidance of sexual activity. I see this commonly in my practice. In adults post-op, I commonly hear that while there may be limitations, the ability to experience intimacy with a partner in a way that is affirming, or simply to be naked and comfortable in one’s body around another person, is worth so much more to them. I know this is not “a study” but it is the experience so many patients have shared with me.”
Puberty blockers stop the maturation process of the reproductive organs, leaving boys with a small penis and lacking the penile tissue needed for vaginoplasty — a sex change surgery that uses genital tissue to create an imitation vagina for men. Rafferty discussed this in his email to the law firm.
“I will also say that a risk you do not mention for trans females who start on blockers early in puberty is that there may not be enough penile tissue to do an inversion and achieve a full depth vaginal cavity. They may take tissue from the GI track or elsewhere to try to extend the cavity but that has led to complications (e.g. GI tissue tends to secrete a lot of mucous and foul odor),” wrote Rafferty.
Rafferty also noted there had been an increase in “top surgery” among teenagers, which he attributed to Medicaid coverage making the surgeries more accessible.
“Today, we have 3 surgeons in [Rhode Island] doing these surgeries and probably half a dozen in [Massachusetts] plus a pediatric plastic surgeon at Boston Children’s specializing in gender surgeries. Most if not all now take Medicaid – very few patients are paying the fully cost of surgery out of pocket. So, the point is that my experience is not that surgery is ‘more popular’ but just more (or simply just) accessible.”
Rafferty did not respond to multiple requests for comment.
Pursuit Of Excellence
On September 15, 2022, WPATH released the SOC-8 without age minimums for child sex-change surgery. Upon its release, Hudson sent an internal memo with the AAP’s statement on the SOC-8, which included a FAQ about the AAP’s policy positions. The FAQ included the question, “What is the AAP’s position on the leaked recommendations on surgeries for minors?” The document gave the following answer: “AAP does not recommend surgical interventions for individuals younger than 18, except in rare cases.”
In December 2022, Jeff Hudson was awarded a Pursuit of Excellence award from the AAP for his work on behalf of “trans” youth, according to a LinkedIn post.
“I am extremely honored to have been awarded the AAP Pursuit of Excellence award for my work on behalf of trans and gender diverse youth,” Hudson wrote in the post.
The AAP previously provided the DCNF with a statement that confirmed their partnership with WPATH but explained that the AAP and peer organizations “develop policy guidance independently.”
“The American Academy of Pediatrics (AAP) routinely partners with relevant U.S. medical and mental health associations and global health organizations on a wide range of health issues, including the World Professional Association of Transgender Health (WPATH),” an AAP spokesperson told the DCNF.
“While this collaboration is important, the AAP develops policy guidance independently, as do its peer organizations.”
The American Academy of Pediatrics and Jeff Hudson did not respond to multiple requests for comment.
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