A Long Overdue Return to Reality in Pediatric Gender Medicine

City Journal | May 12, 2025
Original article can be viewed HERE
Photo Credit: JOSEPH PREZIOSO/AFP via Getty Images

One of President Trump’s first executive orders was the provocatively titled “Protecting Children from Chemical and Surgical Mutilation.” The order directed federally funded insurance programs to end coverage of pediatric sex-trait modification and barred hospitals receiving federal funds from performing such interventions. It also instructed the Department of Health and Human Services (HHS) to conduct a review of the evidence and ethical considerations surrounding pediatric gender medicine.

That review, “Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices,” was released earlier this month. It is already being described as America’s Cass Review, the landmark gender-medicine review published last year in the United Kingdom.

This report is long overdue. While European health authorities in countries like Sweden, Finland, Norway, and the U.K. have moved away from the “gender-affirming” model and toward cautious psychological support for gender-dysphoric children, American institutions have only become more entrenched in the model despite growing evidence of the harm and weak benefits.

The HHS report breaks this trend, providing a comprehensive and sober reevaluation of the science, ethics, and clinical practices in pediatric gender medicine. At more than 400 pages, with chapters on history, terminology, evidence, ethics, and clinical realities, it is the most thorough and ambitious document of its kind in the United States.

The report’s central findings are clear and direct: gender-affirming interventions such as puberty blockers, cross-sex hormones, and surgeries are supported only by low- or very low-quality evidence, while the potential for irreversible harm is substantial. Risks include sterility, sexual dysfunction, impaired bone-density and brain development, psychiatric comorbidities, and surgical complications. The report rejects claims that gender transition reduces suicidality, finding no high-quality evidence to support this oft-repeated assertion. In line with international reviews, it concludes that psychotherapy should be the first-line treatment for youth with gender dysphoria.

Some of the report’s most powerful contributions are found in areas not typically emphasized in such documents. The chapter on terminology is especially significant. Unlike most U.S.-based clinical guidelines, which adopt ideologically loaded terms like “assigned sex at birth,” the HHS report rejects euphemistic language and insists on terminological clarity. It calls out the concept of “gender identity” as scientifically ill-defined, noting that it lacks a stable, observable referent and is inconsistently used even within affirming literature. The report also critiques the classification of children into “cis” and “trans” categories, arguing that this framing falsely reifies identity claims into diagnostic categories and forecloses open exploration. It rightly points out that describing a child as “trans” presupposes the correctness of the gender-identity claim and biases all subsequent treatment decisions.

The report also takes aim at the ideological drift of WPATH, the World Professional Association for Transgender Health. It documents how WPATH’s guidelines shifted over the years from a cautious medical model to an ideologically driven affirmation model in its current Standards of Care, Version 8, promoting early medicalization based on self-declared identity alone. Internal documents reveal that WPATH authors chose language not to reflect evidence-based medical practice but to influence court cases, legislation, and insurance policy.

The HHS report also contains a full chapter on ethics. It argues that informed consent is impossible without first determining whether an intervention is ethically appropriate to offer in the first place. Treatments with low-certainty evidence and known harms cannot be justified simply because a patient wants them. The report also warns that current practices in American gender clinics frequently bypass even minimal safeguards, citing whistleblower accounts and admissions by clinics that patients can begin medical transition after a single short visit.

Critics of the report have fixated on two main points: the anonymity of its authors, and its alleged political bias. On the former, HHS states clearly: “Chapters of this review were subject to peer review prior to this publication, and a post-publication peer review will begin in the coming days involving stakeholders with different perspectives. Names of the contributors to the review are not initially being made public, in order to help maintain the integrity of this process.”

This is standard practice in academia. Journals routinely require authors to remove identifying information during review—a process known as double-blind peer review—to ensure focus on content rather than credentials.

The wisdom of this approach became immediately apparent when metadata in the HHS report’s PDF file revealed that MIT philosopher Alex Byrne may have been one of the contributors. His inclusion alone triggered accusations of bias based solely on his prior critiques of gender ideology. Had all authors been named, the backlash would likely have turned into a witch hunt. By keeping names private, HHS ensures that critics and peer reviewers must engage with the report’s arguments and evidence, not resort to ad hominem attacks.

The second criticism, that the report is politically biased, mistakes correlation for causation. Just because the report’s conclusions align with the Trump administration’s policies does not mean that they are politically motivated. The relevant question is whether the arguments and citations within the report follow the principles of evidence-based medicine. As Canadian commentator Peter Sim noted in his balanced review, the conclusions are consistent with multiple international reviews, and the timing reflects the administration’s desire to make existing evidence available to the public.

This distinction is lost on groups like the American Academy of Pediatrics (AAP) and WPATH, which responded with statements that appeared prewritten. AAP president Susan Kressly claimed the report “fails to reflect the realities of pediatric care” and does not consider the “full breadth of peer-reviewed research.”

As the neuroscientist James Cantor pointed out, “Nothing says ‘I don’t know how evidence-based medicine works’ louder than the demand to ‘consider the totality of available data.’” In evidence-based medicine, he clarified, it is the quality, not the quantity, of research that matters. Systematic reviews exist precisely to filter out low-quality studies and focus only on the most reliable data. That’s why the Cass Review relied on eight systematic reviews to guide its conclusions, and why the HHS report conducted a systematic review of the existing systematic reviews. Their conclusion: the evidence supporting pediatric gender transition remains weak and uncertain.

Another criticism is that the HHS report contradicts or misrepresents the “medical consensus.” But what critics refer to as a “consensus” is often the product of closed-door subcommittees, not open scientific deliberation. The HHS report details how activist groups within major U.S. medical associations developed guidelines for these organizations, often citing each other in circular fashion—a phenomenon sometimes referred to as a citation cartel. These associations often refuse to allow internal dissent or reevaluation of their guidelines, as when the AAP blocked a proposed resolution to review its gender policies.

Consensus-based medicine is only valid if it is rooted in evidence-based medicine. In gender medicine, that link is broken.

If the HHS report has a major shortcoming, it is that it does not go far enough in dismantling the pseudoscience at the heart of gender medicine. While it rightly criticizes the ill-defined notion of “gender identity,” it could have said more about the deeply flawed concept of “brain sex” that underpins much of gender-affirming care. As I and others have argued, studies claiming that transgender individuals have brains like those of the opposite sex suffer from serious flaws, particularly the failure to control for sexual orientation.

Despite this omission, the HHS report is a landmark document. It does what no American medical body has had the courage to do: assess the state of pediatric gender medicine without ideological blinders. It does not bend to euphemism or advocacy language. It does not inflate poor-quality studies to preserve consensus. It does not equate policy with science. Instead, it re-centers the debate on the core question: What does the evidence actually say?

For too long, American medicine has been governed by slogans: “trans kids know who they are,” “affirmation saves lives,” “trust the experts.” The HHS report is a long-overdue invitation to move past slogans and return to science. Let’s hope the medical community has the courage to accept it.

A Long Overdue Return to Reality in Pediatric Gender Medicine

A Long Overdue Return to Reality in Pediatric Gender Medicine

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