The Medical Experts’ Ideology

Three recent briefs I’ve filed trace the modern ideological rot of major American medical associations, at least on contentious policy issues. In United States v. Skrmetti, the American Psychological Association and other medical groups argued that twelve-year-olds have the cognitive maturity to consent to experimental gender transitioning procedures like genitalia removal and chemical sterilization. Yet this term in Chiles v. Salazar, they claimed that minors cannot consent to mere talk therapy that is not immediately affirmative. Invoking the principle of “do no harm,” they proclaimed that “an ethical practitioner should not offer treatments that would harm the patient’s health, or for which no evidentiary basis exists to satisfy a patient’s request.”

Put aside that no evidence shows that talk therapy to explore questions of gender identity is harmful. Put aside too that substantial evidence suggests that immediate affirmation and social transition are harmful. The ultimate irony is that medical gender transitioning of minors consists of “treatments that would harm the patient’s health, or for which no evidentiary basis exists” — but the groups fully support that. The only thread that ties these inconsistent positions together is ideology.

After months of ignoring these criticisms, the APA and other groups have finally responded in a death penalty case pending at the Supreme Court, Hamm v. Smith. The question presented is whether and how courts should assess multiple IQ scores in determining whether a mental disability precludes the death penalty. The APA and tagalong groups have opposed the death penalty in court, even though they cannot plausibly claim any relevant expertise over the fundamentally moral questions involved. But ours is a society that increasingly tends to outsource moral questions to so-called experts, and courts have not been immune from that tendency.

In Hamm, on behalf of America First Legal Foundation, we pointed out that the APA in Skrmetti “waved away all concern about the ability of juveniles to consent to permanently sterilizing sex hormones and surgeries for transitioning purposes, reasoning that adolescents can ‘ha[ve] the emotional and cognitive maturity required to provide informed consent/ assent.’” Yet when it comes to the death penalty, the APA has said “that even criminals who were 20 when they committed murder cannot be subject to capital punishment because they ‘possess a lack of maturity’ and cannot adequately ‘resist outside pressures.’”

The difference, of course, is that the APA morally supports transitioning children and opposes the death penalty. The problem is that these moral views are disguised and exalted as medical expertise to which the rest of us must defer.

The APA finally roused itself to respond — primarily defending the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, while ignoring all evidence of changes to that manual induced by politics. The most remarkable response is buried in a footnote, in which the APA claims that its opposition to the death penalty for 20-year-olds was based “on the conclusion that adolescents are more impulsive than adults.” According to the APA, adolescent impulsiveness “has nothing to do with whether minors ‘ha[ve] the emotional and cognitive maturity required to provide informed consent/assent’” to medical gender transitioning.

Really? “Nothing to do” with it? Does the APA seriously believe that the tendency of adolescents to be “more impulsive” has nothing to do with their capacity to decide between the promise of an immediate fix (via medical hormones or surgery that could be ultimately harmful) and a longer process of psychological therapy? Even transitioning cheerleader World Professional Association for Transgender Health, whose guidance the APA says represents “the consensus in expert opinion,” acknowledges that minors “must be able to reason thoughtfully about treatment options” — warning that adolescence is “associated with increased risk-taking behaviors” and “a sense of urgency that stems from hypersensitivity to reward.”

And the APA is misrepresenting what it told the Supreme Court about the death penalty, anyway. As we had already pointed out, the APA’s death penalty position was not just about impulse control: it said that minors have “[d]evelopmentally immature decision-making, paralleled by immature neurological development.” The APA said this same “immaturity” applies until age 21, “especially in the key brain systems implicated in a person’s capacity to evaluate behavioral options, make rational decisions about behavior, [and] meaningfully consider the consequences of acting and not acting in a particular way.”

The APA ignores all this, presumably because it is impossible to argue that “developmentally immature decision-making” has “nothing to do” with having “the emotional and cognitive maturity required to provide informed consent/assent” to gender transitioning. Those issues are the same. The experts have no clothes.

Much more could be said about the APA. The APA now dismisses as a “[s]tructural bias[]” “a lack of appreciation for qualitative and mixed-methods research” — i.e., non-rigorous research reflecting feelings and “lived experiences” — over quantitative, objective methods. It disdains statistically sound research methods as “epistemologies most closely aligned with Whiteness,” and says that “no one methodological approach is ‘better’” — a position fundamentally at odds with everything we know about evidence-based medicine and the well-accepted hierarchy of evidence. Its past president has urged “the abolition of the death penalty” because “retribution is founded in the unscientific belief that behavior is the result of free will.”

The point is that there is no science here — only ideology. No one should pretend otherwise, at least when it comes to contentious public policy debates.