UpToDate is Out-of-Date on Child Sex Change Interventions

UpToDate is the leading clinical resource, providing comprehensive summaries and detailed health information on a broad array of medical topics to clinicians around the world. UpToDate’s parent company boasts that over three million clinicians use the resource “to make the best care decisions.”

Yet on the subject of so-called “gender-affirming care,” UpToDate is woefully inadequate.

Instead, its “resources” on the topic are misleading and are intended more to advance the “gender affirmation” approach to the treatment of gender dysphoria than to provide anything approaching an accurate summary of pediatric gender medicine literature.

Before diving into the substance, it’s crucial to note that one of the authors of the resource, Dr. Johanna Olson-Kennedy, is not only a prominent advocate for and provider of so-called “gender-affirming care,” but is at the center of multiple controversies.

For one, The New York Times reported that Olson-Kennedy had initially refused to publish the results of a multi-million dollar, federally-funded study that found that “puberty blockers did not lead to mental health improvements” in children; Olson-Kennedy’s decision was due to fears that the results could undermine the argument for “gender-affirming care.” The results of the study were finally released earlier this month, finding that children’s depression symptoms and emotional health “did not change significantly over 24 months” of being on puberty blockers. 

Then, Clementine Breen, a now 20-year-old college student, sued Olson-Kennedy for medical negligence, alleging that Olson-Kennedy’s clinic put her on puberty blockers when she was 12 and performed a double mastectomy on her at 14. 

The other author of the resources, gender activist and child sex change practitioner Dr. Michelle Forcier, was also named in a lawsuit. Forcier allegedly recommended that the child plaintiff take testosterone injections after only one meeting.

It should come as no surprise, then, that the resources authored by Olson-Kennedy and Forcier fail to properly follow the evidence.

Any serious discussion of pediatric gender medicine must reckon with the ever-increasing body of literature showing that child sex change interventions lack sufficient evidentiary support.

Rather than take this into account and grapple with the ethical question of whether children should be subjected to sex change interventions, the UpToDate resources simply assume clinicians provide these procedures to “affirm” their patients’ gender.

As one resource, “Gender development and clinical presentation of gender diversity in children and adolescents,” makes clear, the authors envision the role of the clinician as that of a cheerleader encouraging the child to pursue their “asserted gender identity.” 

“Given the potential mental and physical health consequences of gender diversity in an unaccepting environment, it is important for health care providers to be nonjudgmental and to support their patients in their asserted gender identity,” the clinical summary states.

In other words, the resource suggests that medical providers should operate from the premise that the patient’s asserted identity must be affirmed; transgender medicalization inevitably follows from this position. The very idea of so-called “gender diversity” regressively enforces rigid sex stereotypes, relegating children who do not conform to a lifelong course of experimental body modification.

The authors simply refuse to engage with the wealth of evidence on the harms of child sex change interventions and the corresponding lack of evidence supporting the procedures’ effectiveness.

Neither resource even mentions the Cass Review, the comprehensive review of gender medical services in the United Kingdom that found the evidence supporting the “affirming” approach to be very weak. This is despite the fact that one of the resources, “Management of transgender and gender-diverse children and adolescents,” was last updated in March of 2025, a full eleven months after the publication of the Cass Review. 

That the most authoritative and comprehensive review of the evidence behind pediatric gender medicine would simply be absent from a resource on the topic is indefensible.

Moreover, despite UpToDate being available in over 190 countries, the authors fail to deal with the fact that many countries are moving away from the “affirmation” approach to gender dysphoria.

Health authorities within a number of countries, including the United Kingdom, Sweden, Brazil, and Finland, have restricted child sex change interventions as more and more evidence against these procedures comes to light.

Next, the authors outright mislead the audience on key facts about pediatric gender services.

Specifically, they claim that puberty blockers are “completely reversible.”

This statement simply cannot be made with confidence. 

Artificially preventing a child from going through puberty is inherently experimental, and the true impact on neurocognitive development, which includes executive function, regulation of emotions, and social cognition, is unknown. Not to mention the greater risk of permanent infertility and impaired adult sexual function, particularly if cross-sex hormones are started thereafter.

Sex steroid hormones are critical for bone mineralization and skeletal development. Puberty blockers disrupt this natural process, leading to diminished bone mineral density and concerns about increased fracture risk later in life. Research has shown that these drugs negatively affect bone density, with only partial recovery after sex steroid administration.

Additionally, nearly all children put on puberty blockers go on to take cross-sex hormones, which themselves contribute to infertility and are associated with increased risks of serious health conditions, including heart attack and stroke.

In sum, these resources paint a misleading and distorted picture about the evidence behind – and harms of – so-called “gender-affirming care,” and do so in service of a particular agenda.

Unfortunately, this is not the first instance of UpToDate prioritizing ideology over best practices. Do No Harm’s chairman, Stanley Goldfarb, MD, previously served as editor-in-chief of the kidney section of UpToDate. But when he began questioning the DEI dogma and the malign influence of identity politics on the medical profession, UpToDate’s leadership decided it would be best to part ways. 

UpToDate should take a hatchet to these resources and ensure that they accurately reflect the existing evidence, rather than simply reiterating the maxims of activists.