The Façade of Medical Consensus: How Medical Associations Prioritize Politics Over Science
Chloe K. Jones*
Introduction
Private medical associations are front and center as the nation’s highest court considers the constitutionality of restrictions on “gender-affirming care” for transgender-identifying children. The question before the Supreme Court in United States v. Skrmetti is whether Tennessee’s prohibition of certain medical interventions for minors violates the Fourteenth Amendment’s Equal Protection Clause. Despite the legal nature of that question, the nation’s largest medical associations—or, at least, a few activist leaders within those groups[1]—have dominated the debate.
Courts have traditionally relied on major medical associations as authoritative sources, assuming that their status as “expert[s]”[2] rendered them ideologically neutral. But recent revelations cast doubt on this assumption, causing some to question the associations’ scientific authority.[3] Some of these missteps appear to stem from institutional overconfidence, while others reflect a deeper entanglement between political advocacy and scientific evidence.[4]
One of the most consequential missteps involves medical interventions for transgender-identifying minors. Critics have highlighted two main reasons these groups have declining scientific credibility in this medical sphere. First, independent scientific reviews have identified significant discrepancies between the medical associations’ claims and the quality of scientific data, calling into question these associations’ claims to unbiased expertise. Second, litigation discovery uncovered how the creation of the standards of care for minors was driven, in large part, by political considerations rather than objective evidence.
While the first two criticisms were recent revelations, a neglected third criticism should have been obvious much earlier: the associations have espoused inconsistent views of juvenile psychological development, depending on the political valence of the legal issue at hand. As a case study, this article compares the associations’ amicus curiae briefs in the transgender-identifying-juvenile context with the criminal-defendant-juvenile context. This comparison reveals a striking inconsistency in how these organizations characterize adolescent psychology and decisionmaking. These incompatible scientific conclusions suggest that many associations selectively shape scientific findings to advance specific policy outcomes. If so, courts may justifiably reassess the weight they afford to such amici in future cases.
I. “A United Front”
Long before Skrmetti, activists understood that to win the controversial legal “battle” on gender-transition treatments for minors, the medical field needed to present “a united front.”[5] Through coordinated efforts, these authoritative groups framed procedures like puberty blockers, cross-sex hormones, and surgeries such as double mastectomies as “standard medical care, supported by major medical organizations in the United States.”[6] This perceived consensus became a powerful tool in litigation, often used to argue that state-level restrictions were medically unfounded and constitutionally suspect. If states enacted laws restricting these procedures for minors, attorneys could seek injunctions, citing a “medical consensus [that] is grounded in a wealth of studies” that undermined the states’ safety concerns.[7] Indeed, after states began enacting such restrictions, opponents described the laws as extreme departures from scientific norms and even alleged that they “make it a crime for doctors to act ethically” and increase the likelihood that “some [transgender-identifying children] will die.”[8]
Federal district courts, relying on the asserted consensus, enjoined states from enforcing (what the courts deemed) unconstitutional medical restrictions. For instance, a district judge in Alabama found it significant that “at least twenty-two major medical associations in the United States endorse transitioning medications as well-established, evidence-based treatments for gender dysphoria in minors.”[9] Another in Idaho concluded that these procedures were “safe, effective, and medically necessary” chiefly because they were “accepted by every major medical organization in the United States.”[10] Judges in Arkansas and Tennessee were likewise convinced.[11]
But subsequent developments revealed that this widespread consensus did not derive from a wealth of scientific evidence that was so overwhelming that no reputable medical organization could disagree. Instead, the consensus appears to have been artificially manufactured, driven by a small subset of ideologically driven professionals that “leverage[d] moralized claims and low-quality evidence to promote medical interventions for gender dysphoria in minors.”[12]
II. “An Area of Remarkably Weak Evidence”
Recent scientific reviews undermine the associations’ “medical consensus” claims. Several European nations that once spearheaded treatment regimens for transgender-identifying juveniles have now reversed course, emphasizing caution, with many labeling these procedures as experimental and declaring that their harm to juveniles outweighs any ascertainable benefits.[13] The most prominent review, led by Dr. Hilary Cass on behalf of England’s National Health Service, produced one overarching conclusion: “This is an area of remarkably weak evidence.”[14] Dr. Cass found that other systematic reviews likewise “have demonstrated the poor quality of the published studies, meaning there is not a reliable evidence base upon which to base clinical decisions.”[15] Following Dr. Cass’s findings, the United Kingdom banned all new prescriptions for puberty blockers to minors.[16]
The United Kingdom was not alone. Sweden’s health authority also found the evidence to be “insufficient and inconclusive” with risks “outweigh[ing] the possible benefits.”[17] Neighboring Finland also restricts treatment, requiring psychosocial care first.[18] Groups in France, Australia, and New Zealand likewise discourage “early medicalisation.”[19] Notably, these seismic shifts occurred in progressive countries, signaling that—unlike the United States—scientific positions were not influenced by ideology.[20]
Compounding these doubts, some researchers have attempted to suppress the weak evidence behind these medical interventions. The New York Times recently reported that a long-anticipated, federally funded study of puberty blockers will remain unpublished because its findings suggested that the drugs “did not lead to mental health improvements.”[21] The leading researcher—“one of the country’s most vocal advocates of adolescent gender treatments”—asserted that the study could be “weaponized” and “fuel the kinds of political attacks that have led to bans of the youth gender treatments.”[22] The suppression of negative findings raises concerns about the integrity of scientific discourse in ideologically-charged areas of medicine.[23]
III. “An Untenable Position. . . in Winning Lawsuits”
Litigation discovery revealed further politicization—this time through the creation of the standards of care for transgender-identifying minors. In 2022, an organization of self-appointed experts and activists[24] called the World Professional Association for Transgender Health (WPATH) issued updated standards of care for medical interventions for transgender-identifying minors.[25] Several medical associations issued policy statements adopting these standards wholesale.[26]
But as revealed during discovery in a case concerning Alabama’s law prohibiting puberty blockers, cross-sex hormones, and surgeries on minors, evidence-based science appeared to have little to do with WPATH’s standards. Internal communications showed that WPATH acted on the advice from “social justice lawyers” when it deliberately declined to conduct a systematic review (unlike its European counterparts) before crafting treatment recommendations for minors.[27] They determined that “evidence-based review reveals little or no evidence and puts us in an untenable position in terms of affecting policy or winning lawsuits.”[28] One WPATH author was more succinct: “[W]e need[] a tool for our attorneys to use in defending access to care.”[29] But WPATH went a step further: after hiring Johns Hopkins to review the evidence, WPATH suppressed the publication of the team’s conclusion that “little to no evidence” supported experimental transgender medicine for minors.[30]
The medical associations faced outside political pressure too. Admiral Rachel Levine, President Biden’s Assistant Secretary for Health at the Department of Health and Human Services, met regularly with WPATH leaders and told them that their failure to promptly publish standards of care was “proving to be a barrier to [President Biden’s] optimal policy progress” and that the Administration was “very keen to bring the trans health agenda forward.”[31] Before publishing its guidelines, WPATH confidentially sent Admiral Levine a completed copy.[32] Levine then pressured WPATH to remove its minimum age recommendations for drugs and surgeries on minors, believing that the recommendations would “result in devastating legislation for trans care.”[33] Days before the standards of care were set to be published, WPATH yielded to the Biden Administration’s demands after the American Academy of Pediatrics threatened to oppose the guidelines if WPATH failed to remove the recommendations.[34] These internal communications indicate that WPATH made changes in its clinic guidelines “purely on political considerations,” not on scientific evidence.[35]
IV. “Ebbs and Flows”
In Jones v. Mississippi, Justice Thomas remarked how “curious” it was that the Supreme Court’s “view of the maturity of minors ebbs and flows depending on the issue.”[36] Jones was an Eighth Amendment case involving a minor sentenced to life without parole for homicide. Justice Thomas compared the context of “juvenile murderers”—in which the Supreme Court “has stated that ‘children are different’ and that courts must consider ‘a child’s lesser culpability’”—with the context of abortion rights—in which the Court “take[s] pains to emphasize a ‘young woman’s’ right to choose.”[37]
One likely reason the justices’ conclusions about the maturity of minors ebbs and flows depending on the political context is because—according to the nation’s most prominent medical associations—so does the science. After all, the constitutionality of regulating medical care for transgender-identifying minors is not the only legal sphere in which these medical associations insert themselves as “the voice of America’s medical profession in legal proceedings across the country.”[38] Most of these prominent associations have filed hundreds of amicus curiae briefs[39] nationwide on issues ranging from LGBT rights[40] to immigration.[41]
To see how the associations often chose their positions in these cases to advance policy objectives rather than scientific principles, it’s helpful to compare Skrmetti with another legal context involving minors—juvenile criminal defendants. Nine years before Justice Thomas made his observation in Jones, the Supreme Court considered in Miller v. Alabama whether mandatory life-without-parole sentences for minors were unconstitutional under the Eighth Amendment.[42] The Court answered yes.[43] In doing so, the justices in the majority explicitly relied on the amici curiae support provided by the American Psychological Association and the American Psychiatric Association.[44] Citing their briefs, the majority explained that children possess a unique “capacity for change” because of their “distinctive (and transitory) mental traits and environment vulnerabilities.”[45] Because of minors’ “transient rashness” and “inability to assess consequences,” there is an “enhanced. . . prospect that, as the years go by and neurological development occurs, [their] deficiencies will be reformed.”[46]
The associations’ characterization of juvenile psychology espoused in Miller centered on the minor’s “incomplete identity and ‘sense of self’” and his or her “struggle to define [that] identity.”[47] Science shows how juveniles are “less oriented to the future” and do not consider the consequences of their actions.[48] Indeed, they “lack experience navigating the changing social and environmental contexts, and regulating the new emotional pressures, of adolescence.”[49] The associations explained that “what may be perceived as fixed personality traits in juveniles may in fact result from malleable factors such as present maturity level or social context, rather than engrained or enduring aspects of personality or worldview.”[50] After all, the scientific “[r]esearch has shown that personality traits change significantly during the developmental transition from adolescence to adulthood, and the process of identity-formation typically remains incomplete until at least the early twenties.”[51] Accordingly, the medical associations urged the Supreme Court that the Constitution mandates a lower degree of criminal culpability for juvenile murderers because of “what [the] research confirms: Adolescence is transitory, and juveniles change.”[52]
But the medical associations painted an entirely different portrait of the juvenile mind in their Skrmetti briefs. They abandoned their former citations to the “strong consensus among developmental neuroscientists” regarding “adolescents’ observed psychosocial immaturity,” particularly in the areas of the brain that are “critical” to “functions such as planning, motivation, judgment, and decisionmaking, including the evaluation of future consequences, the weighing of risk and reward, [and] the perception and control of emotions.”[53] Instead, they resolutely affirmed that juveniles are sufficiently mature to provide “informed consent” to the “irreversible” “effects and side effects”[54] of transgender medical interventions, including infertility, “neurocognitive development, psychosexual development[,] and longer-term bone health.”[55] According to the experts, a seventeen-year-old murderer must be constitutionally less culpable because he “still struggle[s] to define [his] identity,”[56] but a nine-year-old girl can consent to the loss of her child-bearing capabilities, despite “the lack of robust information to help [her] make decisions.”[57]
Holding the medical associations to their scientific arguments espoused in Miller, their position in cases like Skrmetti should have been a foregone conclusion—mentally and emotionally immature minors still in the process of forming their identities cannot consent to life-altering and often permanently damaging physical interventions to treat their mental distress and discomfort with their changing bodies. Considering that minors do not appropriately weigh the “corresponding risks and longer-term consequences” of their decisions,[58] the associations should presumably agree with the United Kingdom’s conclusion that “these decisions [are] uniquely difficult for children.”[59]
Likewise, the fact that “impetuous and ill-considered” behavior “is amplified by exposure to peers” should also raise the associations’ alarm bells.[60] According to them, minors’ “actions are shaped directly by” their “peers in ways that adults’ are not,” and they are more likely to “conform to peer expectations to achieve respect and status among their peers.”[61] Given the documented peer pressure that many minors (particularly girls) experience in their decision to identify as transgender, these scientific findings should prompt the associations to adopt, at a minimum, a more hesitant approach to medical interventions for minors.[62] And if the medical associations counted it as “wishful thinking” to expect a juvenile to “resist and control emotional impulses,” especially in “emotionally charged settings,” “to gauge risks and benefits in an adult manner,” or “to envision the future consequences of one’s actions” before “age eighteen or nineteen,”[63] then they cannot expect that a minor could consent to life-altering procedures before that age either.
The associations have never argued that the underlying neuroscience has changed during the brief interim between Miller and Skrmetti. What changed were the policy objectives. The selective application of science reveals an underlying pattern: scientific characterizations are reshaped to fit the preferred legal outcomes. The associations’ inconsistency should have exposed the façade of medical consensus long before discovery revealed the politicization of the WPATH standards and before other countries imposed treatment restrictions.
Conclusion
By promoting a narrative of medical consensus around treatments for transgender-identifying minors, professional medical associations have played a central role in shaping judicial interpretations of constitutional rights. But subsequent scientific reviews, together with revelations from internal communications, have undermined the reliability of that purported consensus. The associations’ tailoring of science to their political ends should have been obvious long before those revelations, given their divergent characterizations of juvenile maturity in the Eighth Amendment context versus the gender-transition context. This comparison suggests a broader concern about the role of ideological advocacy within institutions that purport to offer neutral expertise. As courts continue to rely on the claims of private medical associations in constitutional adjudication, they should do so with particular care—especially when the scientific claims advanced seem to shift in accordance with the litigation context. Judicial deference to claims of professional consensus should be earned through demonstrated objectivity, not assumed as a matter of course.
* Chloe K. Jones is an Appellate Fellow at Alliance Defending Freedom. She graduated from the University of Virginia School of Law and Baylor University.
[1] Medical associations have claimed that, because nearly all major medical associations endorse the practice of cross-sex hormones and puberty blockers for minors, “hundreds of thousands of doctors, researchers, and mental health professionals support gender-affirming care.” Brief for American Psychological Association et al. as Amici Curiae Supporting Petitioners at 16, United States v. Skrmetti, No. 23-477 (argued Dec. 4, 2024) [APA Skrmetti Brief]. Although these professional organizations have thousands of members, they do not assess their members’ support for political statements and litigation strategies. So it is, at best, unclear whether most members of these professional associations endorse these policy positions. Indeed, the evidence we do have supports the opposite contention—these major medical associations do not even consult their professional members when crafting policy documents. In 2022, the American Academy of Pediatrics wrote a letter to the Florida Board of Medicine claiming that it represented 67,000 pediatricians (including 2,600 Floridian pediatricians) in “endors[ing] and recommend[ing]” these medical interventions as the “irrefutable” “standard of care.” See Brief for Florida House of Representatives as Amicus Curiae Supporting Respondents at 6–9, United States v. Skrmetti, No. 23-477 (argued Dec. 4, 2024). Yet in later litigation, the organization was forced to admit that its Florida chapter actually had not even “been involved in the national organization’s policy-making process.” Id. at 8–9. And to the extent the Florida chapter was consulted, it was the organization’s national headquarters that drafted the chapter’s statement to Florida’s health regulators—the chapter president simply “sign[ed] and submit[ed] the comments on behalf of 2,600 Florida pediatricians who apparently were never consulted.” Id. at 11–12.
[2] Brandt v. Rutledge, 551 F. Supp. 3d 882, 891 (E.D. Ark. 2021), aff’d sub nom. Brandt by & through Brandt v. Rutledge, 47 F.4th 661 (8th Cir. 2022).
[3] Vinay Prasad, The AAP (American Academy of Pediatrics) Is Broken, Failed Organization, Sensible Med. (Aug. 27, 2022), https://www.sensible-med.com/p/the-aap-american-academy-of-pediatrics [perma.cc/K4UJ-BQ2W] (discussing the AAP’s “catastrophic errors,” such as giving the wrong medical advice on peanut allergies and the COVID-19 pandemic).
[4] Id.
[5] Christy Olezeski et al., Denying Trans Youth Gender-Affirming Care Is an Affront to Science and Medical Ethics, L.A. Times (June 13, 2022), https://www.latimes.com/opinion/story/2022-06-13/trans-youth-healthcare-state-bans [perma.cc/U9VW-EP5R].
[6] Id.
[7] Brief for Petitioner at 36, United States v. Skrmetti, No. 23-477 (filed Aug. 27, 2024).
[8] Olezeski, supra note 5.
[9] Eknes-Tucker v. Marshall, 603 F. Supp. 3d 1131, 1145 (M.D. Ala. 2022), vacated sub nom. Eknes-Tucker v. Governor of Alabama, 80 F.4th 1205 (11th Cir. 2023).
[10] Poe by & through Poe v. Labrador, 709 F. Supp. 3d 1169, 1182 (D. Idaho 2023), appeal docketed, No. 24-142 (9th Cir. Jan. 9, 2024).
[11] L.W. by & through Williams v. Skrmetti, 679 F. Supp. 3d 668, 709 (M.D. Tenn.), rev’d, 83 F.4th 460 (6th Cir. 2023), cert. dismissed in part sub nom. Doe v. Kentucky, 144 S. Ct. 389 (2023), and cert. granted sub nom. United States v. Skrmetti, 144 S. Ct. 2679 (2024); Brandt, 551 F. Supp. 3d at 891.
[12] Expert Report of Kristopher Kaliebe at 7, Boe v. Marshall, No. 2:22-cv-184-LCB (M.D. Ala. May 19, 2023).
[13] See generally Joshua P. Cohen, Europe and U.S. Diverge Sharply on Treatment of Gender Incongruence in Minors, Forbes (Dec. 2, 2023), https://www.forbes.com/sites/joshuacohen/2023/12/02/europe-and-us-diverge-on-treatment-of-gender-incongruence-in-minors/ [perma.cc/E3QH-N9G8]; Azeen Ghorayshi, Youth Gender Medications Limited in England, Part of Big Shift in Europe, N.Y. Times (Apr. 9, 2024), https://www.nytimes.com/2024/04/09/health/europe-transgender-youth-hormone-treatments.html [perma.cc/7RSX-FG76].
[14] The Cass Review, Independent Review of Gender Identity Services for Children and Young People, 13 (Apr. 2024) https://cass.independent-review.uk/wp-content/uploads/2024/04/CassReview_Final.pdf [perma.cc/3EA6-3ACG] [hereinafter Cass Review].
[15] Id. annex A.
[16] U.K. Department of Health and Social Care, Ban on Puberty Blockers To Be Made Indefinite on Experts’ Advice (Dec. 11, 2024), https://www.gov.uk/government/news/ban-on-puberty-blockers-to-be-made-indefinite-on-experts-advice [perma.cc/6NVW-H7B7].
[17] Jennifer Block, Gender Dysphoria in Young People Is Rising—And So Is Professional Disagreement, BMJ (Feb. 23, 2023), https://www.bmj.com/content/380/bmj.p382 [perma.cc/UGK5-2NYW].
[18] Id.
[19] Id.
[20] Cohen, supra note 13; Leor Sapir, A Consensus No Longer, City J. (Aug. 12, 2024), https://www.city-journal.org/article/a-consensus-no-longer [perma.cc/Q8TD-66F6].
[21] Azeen Ghorayshi, U.S. Study on Puberty Blockers Goes Unpublished Because of Politics, Doctor Says, N.Y. Times (Oct. 23, 2024), https://www.nytimes.com/2024/10/23/science/puberty-blockers-olson-kennedy.html [perma.cc/DD7M-JG85}.
[22] Id.
[23] This is not the only example of suppression. As reported in the same New York Times article, the United Kingdom significantly delayed the publication of a study that found puberty blockers do not change minors’ rates of self-harm. Id.
[24] WPATH president Dr. Marci Bowers explained that it was “important” for each WPATH author “to be an advocate for [transitioning] treatments before the guidelines were created.” Boe v. Marshall, No. 22-184, Doc. 564-8, Unsealed Marci Bowers Dep., 121:7-10, (May 3, 2024), https://www.alabamaag.gov/wp-content/uploads/2025/02/SJ.DX18-564-8-Bowers-Depo-Tr.-UNSEALED.pdf [perma.cc/VQT8-NVCX].
[25] World Pro. Ass’n For Transgner Health, Standards of Care for the Health of Transgender and Gender Diverse People (8th ed. 2022).
[26] Brief for Alabama as Amicus Curiae Supporting Respondents at 11, United States v. Skrmetti, No. 23-477 (argued Dec. 4, 2024) [hereinafter Alabama Skrmetti Amicus Brief] (highlighting the circularity of reasoning when “WPATH authored the initial guidelines, which other groups used as the basis for their recommendations, which WPATH then cited as ‘evidence’ for the next edition of its guidelines”).
[27] Id. at 7.
[28] Id. The state of Alabama argued to the Supreme Court that the United States “strategically chose to seek certiorari in a case with only a preliminary record and no discovery—and then tried to shut down discovery in Alabama on the basis that it had merely filed a cert petition here.” Id. at 4.
[29] Boe v. Marshall, No. 22-184, Doc. 700-10 at 34 (Jan. 6, 2022 Email), https://www.alabamaag.gov/wp-content/uploads/2024/10/SJ.DX181-700-10-WPATH-8-REDACTED-560-31.pdf [perma.cc/MTC2-BFYK].
[30] Research into Trans Medicine Has Been Manipulated, Economist (June 27, 2024), https://www.economist.com/united-states/2024/06/27/research-into-trans-medicine-has-been-manipulated [perma.cc/TN26-V4DD].
[31] Alabama Skrmetti Amicus Brief at 15–16; Azeen Ghorayshi, Biden Officials Pushed to Remove Age Limits for Trans Surgery, Documents Show, N.Y. Times (June 25, 2024), https://www.nytimes.com/2024/06/25/health/transgender-minors-surgeries.html [perma.cc/3GAG-6S4L].
[32] Alabama Skrmetti Amicus Brief at 16.
[33] Ghorayshi, supra note 31.
[34] Alabama Skrmetti Amicus Brief at 19.
[35] Id. at 21.
[36] 593 U.S. 98, 125 n.2 (2021) (Thomas, J., concurring).
[37] Id. at 125 n.2 (emphasis in original) (internal citations omitted).
[38] The Litigation Center, Am. Med. Assoc. (Aug. 22, 2023), https://www.ama-assn.org/health-care-advocacy/judicial-advocacy/litigation-center [perma.cc/25AA-FWSZ].
[39] See, e.g., Brief for American Psychological Association, et al. as Amici Curiae Supporting Petitioner at 2, United States v. Skrmetti, No. 23-477 (argued Dec. 4, 2024) (explaining that the APA has filed nearly 250 amicus briefs) [hereinafter American Psychological Association Skrmetti Amici Brief].
[40] See, e.g., Brief for American Medical Association, et al. as Amici Curiae Supporting Employees, Bostock v. Clayton County, 590 U.S. 644 (2020) (No. 17-1618).
[41] See, e.g., Brief for the Association of American Medical Colleges, et al. as Amici Curiae Supporting Respondents, Trump v. Hawaii, 585 U.S. 667 (2018) (No. 17-965).
[42] 567 U.S. 460 (2012).
[43] Id. at 470.
[44] Id. at 471 n.5.
[45] Id. at 473.
[46] Id. at 472 (quotation omitted).
[47] Brief for American Psychological Association, et al. as Amici Curiae Supporting Petitioner at 19–20, Miller v. Alabama, 567 U.S. 460 (2012) (No. 10-9647) [hereinafter American Psychological Association Miller Amici Brief].
[48] Id. at 3–4.
[49] Id. at 10.
[50] Id. at 19–20.
[51] Id. at 20.
[52] Id. at 35.
[53] Id. at 25–26.
[54] Brief for American Academy of Pediatricians, et al. as Amici Curiae Supporting Petitioner at 14, United States v. Skrmetti, No. 23-477 (argued Dec. 4, 2024); see also American Psychological Association Skrmetti Brief at 11, 24 (explaining how physicians can be “careful” by seeking “informed consent” from juvenile patients).
[55] Cass Review, supra note 14, at 196.
[56] American Psychological Association Miller Amici Brief at 20.
[57] Cass Review, supra note 14, at 195–96.
[58] American Psychological Association Miller Amici Brief at 12; see also Brief for American Medical Association, et al. as Amici Curiae Supporting Petitioner at 2–3, Miller v. Alabama, 567 U.S. 460 (2012) (No. 10-9647) [hereinafter American Medical Association Miller Amici Brief].
[59] Cass Review, supra note 14, at 195.
[60] American Psychological Association Miller Amici Brief at 5, 7.
[61] Id. at 15, 18; see also American Medical Association Miller Amici Brief at 3.
[62] Cass Review, supra note 14, at 122.
[63] American Psychological Association Miller Amici Brief at 10, 13–15 (citations omitted).