Evidence Over Politics: Rethinking Gender Medicine in Psychiatry and Beyond

This past May I had the opportunity to attend the American Psychiatric Association (APA) annual meeting in Los Angeles along with Ian Kingsbury, Do No Harm Director of Research, and Dr. Miriam Grossman, Do No Harm Senior Fellow. It was the first time I came as an exhibitor, and it has been at least a decade since I’ve been a full program attendee. I entered as part of Do No Harm, and to hear – for what I believe was the first time – general sessions on both sides of the debate surrounding the care of minors with gender dysphoria.

Serious concerns surrounding the evidence for pediatric medical transition – puberty blockers, cross-sex hormones, and surgeries – are not unique. Systematic reviews reveal the very low quality of evidence for any beneficial effects compared to the risk of significant, irreversible harms. Even the World Professional Association for Transgender Health (WPATH) itself noted in its Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 (SOC-8) that a “key challenge in adolescent transgender care is the quality of evidence evaluating the effectiveness.” It goes on to state that “adolescents, their parents, and care providers should be informed about the nature of the evidence base.”

Yet, WPATH has not heeded its own warning, leading professional medical associations to unfortunately place the cart before the horse in issuing guidance before appropriately assessing the evidence. Prior to understanding or performing systematic reviews, many organizations within the medical establishment made their policy position known. The American Academy of Pediatrics (AAP), for example, issued a Policy Statement in 2018, which it later reaffirmed in 2023, fully supporting an “affirming” model, and nothing else. And while the AAP called for a “systematic review of the evidence” in 2023, none has yet to be delivered.

The same goes for the American Psychiatric Association, whose Assembly and Board of Trustees approved a Position Statement in 2020 supporting “access to affirming and supportive treatment for trans and gender diverse youth and their families, including appropriate mental health services, and when indicated puberty suppression and medical transition support.” An affirming model was fully and solely endorsed; reference to “mental health and social support services” was merely mentioned in the context of “navigat[ing] the gender affirmation process.”

The Europeans followed a different course than our U.S.-based medical societies. Finland, Sweden, and the United Kingdom issued systematic reviews to inform their analysis. Their work highlighted the low quality of evidence for an affirming model that includes puberty blockers, hormones, and surgeries for children and adolescents with gender dysphoria. They found a lack of evidence supporting the safety and efficacy of these treatments in minors. Caution was strongly advised and these otherwise experimental medical and surgical interventions were sharply restricted. Clear priority was given to psychosocial support and psychotherapy.

Despite the evidence from overseas, many U.S. medical organizations maintain a pro-affirmation stance and have historically silenced debate in the face of any disagreement. However, the 2025 APA annual meeting showed signs of change. For one, Do No Harm’s exhibit allowed for meaningful one-on-one conversations with many attendees. We spoke with those caring for youth with gender dysphoria as well as students just learning about this condition. Our discourse was free and open. I’m encouraged to think these same open-minded individuals will also give a fair reading to the Department of Health and Human Services’ report on this topic.

Moreover, the APA talks on the subject were highly informative, and perhaps for some, eye-opening especially when juxtaposed with one another. One session in particular looked at the data from Europe and the role of systematic reviews. Drs. Christian Monsalve, Stephen Levine, Kristopher Kaliebe, and Kathleen McDeavitt did a phenomenal job in clearly and professionally reviewing the evidence. Credit goes to these outstanding speakers as well as Dr. Michael Myers, Chair of the Scientific Program Committee, for making this happen.

I also applaud the persistence of those who have been petitioning the APA for this conversation. I understand these efforts to raise serious and legitimate concerns regarding pediatric medical transition have been a long time coming to a national meeting like the one I recently attended. For years, dissenting views within the medical community that challenged the prevailing narrative around so-called “gender-affirming care” were effectively muted. May this silencing finally have come to an end.

Indeed, the moment has arrived for the APA – and other specialty medical societies – to demonstrate responsible leadership and change course from the past. Duty to the members of these associations, the integrity of medical practice, and, most importantly, the patients themselves, demands an open and rigorous examination of the evidence. Systematic reviews cannot be ignored. Neither can the serious risks associated with the current affirming model. Frankly, this exercise should have transpired within organized medicine well in advance of one-sided policy statements, which unfortunately have been informed more by politics than solid evidence.

In this regard, debate must occur in an honest and transparent manner throughout the halls of medicine. Medical societies should not fear the public, but welcome their desire for knowledge. If medical societies like the APA seek to earn the public’s trust at this point in the debate, then these medical associations need to dialogue openly and truthfully.

While the press was, unfortunately, not permitted at these sessions of the APA, this practice must end. The closed doors must be opened. Silence gives the sense of a false unanimity that only so-called “gender-affirming care” is supported by the medical community, when in fact there are many physicians with grave concerns about the harms these interventions have on youth.

Today we are at a critical moment. A careful review of the HHS report is essential. As an umbrella review, seventeen systematic reviews met the report’s inclusion criteria. And, as with the various European analyses, the conclusion was clear: The overall quality of evidence regarding the psychological, quality of life, and long-term health effects of pediatric medical transition is very low. In other words, the reported benefits of these interventions are likely to be significantly different from actual outcomes.  

The evidence also indicates these interventions are not lifesaving. Yet, some physicians advocating for pediatric medical transition pressure anxious parents by citing an alleged increased risk of suicide, a claim that is both unfounded and unethical, as noted in the HHS report. Likewise, serious, irreversible risks of these interventions must not be overlooked, including infertility, sexual dysfunction, impaired bone mineral density, cardiovascular ailments, surgical complications, and regret, the latter of which the true rate is simply not known.

More so, the role of physician extends beyond mere technical expertise. Doctors have a duty to thoughtfully consider a minor’s inability to consent or assent to treatment and the ethical implications of their clinical recommendations in light of this reality. The Boe v. Marshall case underscored this concern, as the Johns Hopkins University team, which was contracted by WPATH as part of SOC-8, found insufficient evidence to support the claim that adolescents possess the capacity to consent to these interventions. Furthermore, when considering issues like fertility, we must recognize that an adolescent’s limited life experience places significant limitations on his or her ability to truly comprehend future desires.

From an ethical standpoint, it is also important to recognize that patients do not have an inherent right to medications and procedures that lack demonstrable benefit. Autonomy, while valued, is not the sole guiding ethical principle in medical decision-making. Physicians must also remember both beneficence and nonmaleficence, ensuring that their recommendations prioritize the patient’s well-being and safeguard against harm. Physicians must move beyond “have it your way” medicine and remember they’re not working for Burger King but rather caring for people. May that sacred duty never be forgotten.

Psychiatrists, too, must not abandon the essential role they play in the care of minors with gender dysphoria. The vast majority of these children have co-occurring psychiatric conditions or have experienced significant trauma – factors that warrant careful evaluation and treatment. In fact, high-quality psychotherapy first requires a comprehensive understanding of the underlying and sustaining factors contributing to a patient’s distress. Subsequently, psychotherapeutic approaches such as cognitive behavioral therapy, dialectical behavioral therapy, psychodynamic psychotherapy, and family therapy, among others, can offer meaningful impact. Clearly, these non-invasive options should serve as an obvious first-line treatment.

The APA’s recent meeting marks progress toward open discourse and more ethical practice. While past policy statements have been issued without comprehensive systematic reviews, the willingness to engage in debate signals a shift toward greater intellectual rigor. However, much more is needed from medical associations, specifically policies and guidelines grounded in science and the evidence base. Ultimately, the APA – and other specialty societies – must revisit their own position statements on pediatric medical transition. An update is sorely needed given the data before us. Ending pediatric medical transition and moving toward genuine psychosocial support and psychotherapy is essential to prioritizing the long-term health and well-being of children suffering from gender dysphoria.