Department of Health and Human Services – Over the past decade, the number of children and adolescents who question their sex and identify as transgender or nonbinary has grown significantly.
Many have been diagnosed with a condition known as “gender dysphoria” and offered a treatment approach known as “gender-affirming care.”
This approach emphasizes social affirmation of a child’s self-reported identity; puberty suppressing drugs to prevent the onset of puberty; cross-sex hormones to spur the secondary sex characteristics of the opposite sex; and surgeries including mastectomy and (in rare cases) vaginoplasty.
Thousands of American children and adolescents have received these interventions.
While sex-role nonconformity itself is not pathological and does not require treatment, the use of pharmacological and surgical interventions as treatments for pediatric gender dysphoria has been called “medically necessary” and even “lifesaving.”
Motivated by a desire to ensure their children’s health and well-being, parents of transgender-identified children and adolescents often struggle with how best to support them. Many of these children and adolescents have co-occurring psychiatric or neurodevelopmental conditions, rendering them especially vulnerable.
When they seek professional help, they and their families should receive compassionate, evidence-based care tailored to their specific needs.
Society has a special responsibility to safeguard the well-being of children. Given that the challenges faced by these patients intersect with deeply contested issues of moral and social significance—including social identity, sex and reproduction, bodily integrity, and sex-based norms of expression and behavior—the medical practices that have recently emerged to address their needs have become a focus of significant controversy.
This Review is published against the backdrop of growing international concern about pediatric medical transition. Having recognized the experimental nature of these medical interventions and their potential for harm, health authorities in a number of countries have imposed restrictions.
For example, the UK has banned the routine use of puberty blockers as an intervention for pediatric gender dysphoria.
Health authorities have also recognized the exceptional nature of this area of medicine. That exceptionalism is due to a convergence of factors.
One is that the diagnosis of gender dysphoria is based entirely on subjective self-reports and behavioral observations, without any objective physical, imaging, or laboratory markers. The diagnosis centers on attitudes, feelings, and behaviors that are known
to fluctuate during adolescence.
Additionally, the natural history of pediatric gender dysphoria is poorly understood, though existing research suggests it will remit without intervention in most cases.
Medical professionals have no way to know which patients may continue to experience gender dysphoria and which will come to terms with their bodies.
Nevertheless, the “gender-affirming” model of care includes irreversible endocrine and surgical interventions on minors with no physical pathology. These interventions carry risk of significant harms including infertility/sterility, sexual dysfunction, impaired bone density accrual, adverse cognitive impacts, cardiovascular disease and metabolic disorders, psychiatric disorders, surgical complications, and regret.
Meanwhile, systematic reviews of the evidence have revealed deep uncertainty about the purported benefits of these interventions.
The controversies surrounding the medical transition of minors extend beyond scientific debate; they are deeply cultural and political. Public discourse is dominated by intensely polarizing narratives. Some view the medical transition of minors as a pressing civil rights issue, while others regard it as a profound medical failure and a sobering reminder that even modern medicine is vulnerable to serious error.
In the midst of this highly charged debate, children and adolescents, and their families—
who seek only to support their flourishing—have found themselves caught between competing perspectives. They require, and are entitled to, accurate, evidence-based information to guide their decisions.
This Review of evidence and best practices was commissioned pursuant to Executive Order 14187, signed on January 28, 2025. It is not a clinical practice guideline, and it does not issue legislative or policy recommendations.
Rather, it seeks to provide the most accurate and current information available regarding the evidence base for the treatment of gender dysphoria in this population, the state of the relevant medical field in the United States, and the ethical considerations associated with the treatments offered.
The Review is intended for policymakers, clinicians, therapists, medical organizations and, importantly, patients and their families.
It summarizes, synthesizes, and critically evaluates the existing literature on best practices for promoting the health and well-being of children and adolescents with distress related to their sex or to social expectations associated with their sex. Treatment of adults constitutes a separate topic and is not addressed in this Review.
A summary of the Review’s main findings is presented below.
