The HHS released a highly anticipated literature review on Thursday that pushes providers to rely on behavioral therapy when treating gender dysphoria in those under 19 and broadly disavows gender-affirming care options, including hormone therapies, puberty blockers and surgeries.
While the report stops short of making policy recommendations and is not clinical guidance, it does mark a departure from standards issued by the World Professional Association for Transgender Health, a nonprofit organization dedicated to evidence-based research on transgender healthcare.
The American Medical Association, American Psychological Association and the American Academy of Pediatrics have independently endorsed recommendations from WPATH, which advocates for a social, psychological, behavioral and medical approach to treating gender dysphoria. However, President Donald Trump has repeatedly condemned the organization as being politically motivated.
In January, the president issued an executive order calling for the federal government to stop financially supporting providers who offer gender-affirming care for minors and asked HHS to conduct its own research into best practices for treating gender dysphoria in those under the age of 19.
The resulting report, which spans 409 pages, said WPATH had falsely perpetuated a narrative that there was consensus about how to treat teens struggling with their gender identity and had “suppressed dissent and stifled debate” among professionals.
The HHS leaned heavily on findings from a controversial 2024 British report, called the Cass Review, to offer a counter-narrative. The Cass Review argues there is a lack of long-term evidence supporting puberty blockers and hormone therapies for teens and should only be used experimentally. The report has been heavily scrutinized for relying on low quality research, with skeptics saying the author, Hilary Cass, “likely” excluded relevant studies. Cass reported excluding some studies for methodological reasons, while at other times the scholar offered no justification for excluding research.
The HHS review also included testimony from five whistleblowers, who worked at clinics and allegedly saw gender-affirming treatments cause patients harm.
The agency said the review, in total, revealed gender-affirming care had “significant risks” for patients while offering “very weak evidence of benefit.”
Instead, the HHS advocates for increased use of behavioral or “exploratory” therapy, which the agency never fully defines. The report does seek to distance its recommendation from the term “conversion therapy” — which 20 states, Puerto Rico and Washington, D.C. have laws limiting or outlawing in some capacity, according to the Human Rights Campaign.
“There is a dearth of research on psychotherapeutic approaches to managing gender dysphoria in children and adolescents. This is due in part to the mischaracterization of such approaches as ‘conversion therapy,’” the report said. “Psychotherapy is a noninvasive alternative to endocrine and surgical interventions for the treatment of pediatric gender dysphoria.”
Still, a name may only be a name.
“The report’s framing of psychotherapy as an alternative to medical affirmation — especially in a way that delays or discourages access to competent gender-affirming care providers — echoes the same ideology and pathologizing practices that underpinned past conversion therapy practices,” said Arjee Restar, social and legal epidemiologist at Yale University who has previously written about youth gender-affirming care practices, by email.
Accusations of overreach
National Institutes of Health Director Jay Bhattacharya cheered the report in a statement Thursday.
“Our duty is to protect our nation’s children — not expose them to unproven and irreversible medical interventions,” said Bhattacharya. “We must follow the gold standard of science, not activist agendas.”
However, some physicians, medical researchers and analysts were quick to say the HHS was doing exactly that — attempting to assert its own agenda over scientific consensus.
“If you look at basically any other crumbling democracy, one of the first things to start to happen is the government begins to make medical decisions for its populace via policy.”
Meredithe McNamara
Assistant professor of pediatrics at the Yale School of Medicine
“This report is pure politics masquerading as science,” said Kellan Baker, executive director of the Institute for Health Research and Policy at Whitman-Walker, over email. “The ultimate goal of this report is to impose a political agenda in place of science and to insert the federal government where it does not belong—between healthcare providers and the families and patients they care for.”
Experts interviewed for this piece balked at the use of anecdotes to inform policy recommendations, as well as the HHS’ refusal to detail who authored the review. The agency said in the press release it was withholding authors’ names to “maintain the integrity of this process.”
“That’s just simply nonsense,” said Meredithe McNamara, assistant professor of pediatrics at the Yale School of Medicine and cofounder of the Integrity Project, which seeks to promote sound science in child and adolescent health policy. “That’s not how scientific integrity works. If people are not willing to put their names on it, then it should not be taken seriously.”
McNamara went on to say that the agency’s purported issue with a lack of long-term studies on gender-affirming care was out of step with how the medical field routinely relies on observational studies to advance care practices.
“I think that every intervention that is only recently widely available — which is a fair way to describe gender-affirming medical care within the past 10 years or so — begins with observational studies of a duration of a few years at a time,” she said. “The positive findings are just kind of deleted and discarded from these contrived, biased evidence reviews [cited in the report].”
Susan Kressly, president of the American Academy of Pediatrics, echoed that sentiment in a statement shared Thursday, saying she was “deeply alarmed” by the report.
“For such an analysis to carry credibility, it must consider the totality of available data and the full spectrum of clinical outcomes rather than relying on select perspectives and a narrow set of data,” Kressly said. “This report misrepresents the current medical consensus and fails to reflect the realities of pediatric care.”
However, Stanley Goldfarb, chairman of Do No Harm, a group that aims to protect healthcare from the “disastrous consequences of identity politics,” fully endorsed the report, saying it “rightfully exposes a number of serious risks in the medical transition of young people.”
“It is clearer now more than ever that we must end this misguided practice and replace it with evidence-based treatment for gender confused kids,” Goldfarb said.
The report is part of a series of escalating actions taken by the administration to limit youth transgender Americans’ access to healthcare and medical research on associated treatments.
Earlier this week, Trump said he had tasked the Department of Justice with investigating parties that enable gender-affirming care for minors, including providers that performed services and companies that “misled the public about the long-term side effects” of treatments under the Food, Drug and Cosmetic Act.
The administration has also created a website where concerned parties can act as whistleblowers on gender-affirming care, and has proposed establishing a private right of action, with a long statute of limitations, to allow children or their families who have received gender-affirming care treatments to sue for damages.
Wider fallout could follow
Trump’s focus on the transgender population is outsized. Although the administration has repeatedly stated “many” children have been diagnosed with gender dysphoria, in reality only about 1% have such a diagnosis, and only a fraction who do receive treatment, according to a research letter published in JAMA in January.
Yet the president is not alone in seeking to reduce youth transgender care access. Across the country, 26 states have issued bans on gender-affirming care, according to a Human Rights Campaign tracker. A number of those bans are being challenged in court, including Tennessee’s, which is awaiting a ruling from the U.S. Supreme Court this summer.
Should the court decline to issue a sweeping ruling — similar to how it has taken a piecemeal approach to state-level abortion bans — the literature review could appear in courtroom battles over healthcare access.
Currently, plaintiffs seeking to preserve youth healthcare access have broadly appealed to WPATH guidance. However, many conservative-leaning judges have demonstrated a leeriness toward accepting the recommendations.
Chief Judge Jeffrey Sutton, for example, who wrote the appellate court’s majority opinion upholding Tennessee’s ban in the Court of Appeals for the 6th Circuit, said that medical protocols were “ever-shifting.” He said it was difficult to determine a bright line of what constituted “medically necessary care,” despite hearing doctors rattle off WPATH guidance and extoll the benefits of hormone treatments.
Now, Thursday’s literature review dedicates 30 pages to discrediting WPATH. Should attorneys general enter it into evidence, the guidance could offer judges further ammunition to cast aside the medical community’s recommendations on gender-affirming care.
“If this report is presented, plaintiffs seeking to protect access to gender-affirming care will have an opportunity to criticize its claims, credibility and approach, including the report’s heavy reliance on the U.K. Cass Review,” said Suzanne Goldberg, professor of law at Columbia Law School and director of the Sexuality and Gender Law Clinic, noting courts have a responsibility to interrogate evidence presented.
Still, providers seeking to offer gender-affirming care for youths are increasingly in a hostile climate. Already, several providers have suspended services in light of Trump’s crackdown, including Children’s Healthcare of Atlanta, Penn State Health, UPMC and Lurie Children’s Hospital of Chicago.
McNamara said the government’s reach to guide medical practices is unprecedented.
“If you look at basically any other crumbling democracy, one of the first things to start to happen is the government begins to make medical decisions for its populace via policy,” she said. “This feels really shocking and unusual, and we can’t forget that.”
