The American College of Pediatricians (ACPeds) is a professional organization of physicians and other pediatric healthcare professionals dedicated to the care of children and the ethical principle of first do no harm. ACPeds promotes recommendations expected to yield optimal health outcomes for youth from conception through young adulthood. Contrary to the claims of some Western governments, academic, medical, and psychological associations, transgender-affirming interventions, including social transition, puberty blockers, cross-sex hormones, and surgeries, are neither evidence-based nor the international standard of care for youth with gender dysphoria (GD). Since 2019, there have been several systematic reviews and the 2024 Cass Independent Review of the world’s scientific literature regarding transgender affirmation of childhood and adolescent gender dysphoria. All have concluded that support for pediatric gender transition is based on low to very low-quality evidence and therefore must be considered experimental. This means the alleged benefits put forth in pro-pediatric transition studies are likely not true due to significant design flaws in those studies.[1], [2], [3], [4], [5], [6], [7] As a result, the UK, Sweden, Finland and Denmark have greatly restricted the use of transgender-affirming interventions among youth with gender dysphoria, and instead recommend comprehensive psychotherapy to address underlying issues and comorbid conditions.[8] Norway may soon follow suit since all four of its regional health councils recently determined that puberty blockers and cross-sex hormones for gender-distressed minors are experimental treatments that should be restricted to clinical trials.[9]  The best available evidence indicates that nations promoting pediatric transgender-affirming interventions should reverse course, and nations that have yet to embrace pediatric transgender-affirming interventions should maintain this position. 

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Gender dysphoria (GD) of childhood and adolescence describes a psychological condition in which youth express a marked incongruence between their experienced gender and their sex. The associated emotional distress may result in impaired social function. However, when this occurs in the pre-pubertal child, GD resolves in the vast majority of patients by young adulthood.[10] Prior to the 21st century, the international standard of care for GD in children was watchful waiting with or without psychotherapy. The protocol of socially, chemically, and surgically altering children’s bodies to match their incongruent gender beliefs first arose in the Netherlands for only the most resistant cases of pediatric GD. Between 2007 and 2016, however, this “Dutch Protocol” as it was initially called, gradually became widespread across Western nations with social affirmation being recommended for all gender incongruent children regardless of age.[11] The pervasive application of this protocol, beginning with social transition for children as young as 18 months of age, and puberty blockers as young as 8 years of age, followed by cross-sex hormones, is rooted in the ideological assumption that a transgender identity is innate. Significant debate over the protocol’s expansion arose because pubertal suppression with gonadotropin-releasing hormone (GnRH) agonists (puberty blockers) followed by the use of cross-sex hormones can result in the permanent sterility of minors as well as other long-term iatrogenic diseases across the lifespan. What follows is a brief review of important definitions, the protocol’s potential harms, and how to best uphold the ancient medical ethics principle of “first do no harm” while effectively identifying and treating the underlying causes of gender dysphoria in youth. 

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Normality has been defined as “that which functions according to its design.”[12] One of the chief functions of the brain is to perceive physical reality. Thoughts that are in accordance with physical reality are normal. Thoughts that deviate from physical reality are abnormal—as well as potentially harmful to the individual and others. This is true whether or not the individual who possesses the abnormal thoughts feels distress. A person’s belief that he is something or someone he is not is, at best, a sign of confused thinking; at worst, it may be a delusion. Just because a person thinks or feels something does not make it reality. This would be true even if abnormal thoughts were biologically hardwired, which they are not. 

Sex is an objective biological trait that can be diagnosed with medical tests; gender identity is not. The norm for human development is for an individual’s thoughts to align with physical reality, for an individual’s gender identity to align with his or her sex. People who identify as “feeling like the opposite sex” or “somewhere in between” remain biological males or biological females. Gender dysphoria (GD) is a problem that resides in the mind, not in the body. Children with GD do not have a disordered body—even though they may believe and feel as if they do. Similarly, a child’s distress over developing secondary sex characteristics does not mean that puberty should be treated as a disease because puberty is not, in fact, a disease.  

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Sex is a binary biological trait determined at fertilization that declares itself in utero and is acknowledged at birth. To understand what sex is, one must first identify and distinguish between what defines sex and what determines sex. In the life sciences, sex is defined by how that organism is structured to function during the reproductive act.[13] The primary purpose of the reproductive system is to propagate the species. Among organisms that reproduce sexually (whether plant or animal), the structure of the sexual reproductive system consists of two complementary halves. Sexual reproduction requires the union of these two halves—the union of exactly two distinct sex cells, which arise from exactly two distinct sets of sexual organs—to form a new organism. Organisms whose reproductive organs are structured to donate genetic material during the reproductive act are designated male. Organisms whose reproductive organs are structured to receive that genetic material during the reproductive act are called female. This is why sex is a binary trait. In humans, sex is determined at fertilization by sex-determining genes on the sex chromosomes.[14] Every nucleated cell in a person’s body—every organ—has the same sex chromosomes. Thus, no one is born with an ‘opposite-sexed brain’; no one is ‘born in the wrong body’. The sex-determining genes in individuals with XY chromosomes result in the development of male gonads (testes), which produce male sex cells (sperm). Sex-determining genes in individuals with XX chromosomes result in the development of female gonads (ovaries), which produce female sex cells (ova). Since social affirmation, drugs, and surgeries do not change a person’s genetics, they also do not change a person’s sex. This is why sex is a binary, innate, and immutable trait across the human lifespan from fertilization forward.

 

Some ideologues claim intersex conditions prove sex is a spectrum and that the sex binary is a social construct. This is false. Intersex conditions are not additional sexes on a spectrum. Intersex conditions are rare disorders that occur during the development of the normal binary reproductive system of unborn males and females. The medical term for intersex conditions is Disorders of Sexual Development (DSD). DSDs are abnormal conditions that fall into one of two categories. One set of DSD includes disorders like congenital adrenal hyperplasia (CAH), which causes infants to be born with ambiguous genitalia. Infants with ambiguous genitalia do not represent a new sex because they do not possess any new reproductive sex cells. Further medical testing will, in fact, reveal that they are either male or female. A second set of DSD, including but not limited to complete androgen insensitivity syndrome (complete AIS), is associated with unambiguous genitalia but causes patients’ physical appearance (phenotype) to be inconsistent with what their sex chromosomes (genotype) would predict. For example, due to a genetic abnormality, phenotypic females with complete AIS are found to have XY chromosomes.[15] Here again, the genetic abnormality fails to produce new functional sex cells; complete AIS is not another sex. Abnormalities, genetic or otherwise, that affect the reproductive system are disorders – not a spectrum of functional human sexes. DSD (intersex conditions) are medically diagnosable disorders of the body that result in deficiencies and/or malformations of the normal male/female reproductive system. Additionally, all categories of DSD have been associated with reduced fertility.[16] Although the majority of males and females with DSD can be successfully diagnosed and treated, affected individuals experience varying degrees of suffering. For all of these reasons, intersex conditions are correctly understood as disorders of sex development. Fortunately, DSDs are exceedingly rare, occurring in only 0.02% of the general population.[13] 

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For similar reasons, people who possess different combinations of sex chromosomes, such as females with Turner’s Syndrome and an XO karyotype or males with Klinefelter’s Syndrome who possess an XXY karyotype, also do not violate the sex binary. To represent an additional sex, one must possess a new functional reproductive sex cell (something other than male sperm or female eggs that can result in human offspring). The absence of an X chromosome does not result in these individuals producing new sex cells. Individuals with Turner’s Syndrome are anatomically female, as would be expected in the absence of a Y chromosome. Similarly, individuals with Klinefelter’s do not represent an additional sex; they are anatomically male as directed from fertilization by the presence of male sex-determining genes on their Y chromosome. 

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Gender identity, in contrast to sex, is neither innate nor immutable. There is no medical test to identify people who claim to be ‘transgender’ because a ‘transgender identity’ exists only in the mind not in the body. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), gender is defined as the “lived role” of male or female, resulting from the interaction of cultural and psychological factors with a person’s biological constitution.[17] Gender identity is defined similarly as “a category of social identity” that is determined by the interaction of cultural, psychological, and biological factors.[15] Gender identity is shaped by many factors and not determined by genetics alone, so it is not surprising that incongruent gender identities have long been documented to align with sex during childhood, adolescence, and adulthood. In other words, gender dysphoria has long been documented to desist across the lifespan, and this remains true today.[18] A recent landmark study, due to its prospective, 15-year longitudinal and population-based design, found that even among this generation of youth, a majority will outgrow their gender distress by age 25.[19]

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Prior to widespread social and medical transgender interventions, it was widely acknowledged that the vast majority of young children with gender incongruence outgrew it by young adulthood when supported through natural puberty.[20]  Most gender-dysphoric teens are girls and boys who are anxious, depressed, traumatized, and uncomfortable with their bodies and struggling with their identity.[21] Research suggests gender dysphoria arises from the interaction of many factors from at least three categories. These categories include a person’s biological predispositions and psychological vulnerabilities (e.g.: certain personality traits, autism/other neurologic difference and/or mental illness), plus one or more of a person’s environmental factors (e.g. childhood traumas, parent mental illness, social contagion via friend groups and social media, etcetera).[22] For example, two rigorous studies found that the vast majority of  self-identified transgender youth experienced on average five childhood traumas and/or suffered from mental illness, including suicidal thoughts, before developing signs of gender dysphoria or expressing a transgender identity.[23], [24]  Since these studies reveal that traumas, mental illness, and suicidal thoughts occur prior to any sign of gender dysphoria, one cannot conclude that lack of social affirmation and other transgender interventions are the cause of their mental illness and suicidal ideation. Instead, one can hypothesize that the preceding traumas and mental illness may be causing both the suicidal ideation and GD. This hypothesis is consistent with the many studies that demonstrate children and teens with GD can come to embrace their bodies through counseling alone.[25] 

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Puberty is not a disease. It is a critical window of normal physical, cognitive, emotional, psychological, social, and spiritual development that is permanently disrupted by puberty blockers. When normal puberty is artificially arrested with puberty blockers, valuable time is forever stolen from these children, time that should be spent in normal development. This time, during which highly significant and irreplaceable advances in bone, brain, social, emotional, spiritual, and sexual maturation occur, is time in normal and active development – that can never be given back.

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Lupron is one of the most commonly prescribed puberty blockers and lists the following side effects in its package insert: emotional lability, worsening of current psychological illness or new onset psychological illness.[26] In light of this, it is no surprise that one British study revealed that after a year of receiving puberty blockers, the mental health of 34% of GD youth deteriorated, and another 37% experienced no improvement.[27] Another British report found that gender-distressed girls exhibited more self-harm and emotional problems and greater body dissatisfaction while taking puberty blockers.[28] All puberty blockers, including Lupron, arrest pubertal development by acting on the brain. Boys are chemically castrated, and girls are chemically driven into premature menopause for as long as the puberty blockers are used. This developmental arrest may result in permanent sexual dysfunction, infertility, bone loss, and potentially altered brain development with cognitive impairment.[29], [30]

 

As previously stated, prior to pervasive social and medical affirmation of incongruent gender identities, the majority of gender dysphoric youth would embrace their bodies by young adulthood. When gender-dysphoric youth are instead socially affirmed as “trans” and given puberty blockers, nearly 100% of them persist in their “transgender” belief and request cross-sex hormones.[31] This suggests that social transition and puberty blockers “lock” kids into their gender incongruence. This is particularly troubling ethically because when blocked in early puberty and later given cross-sex hormones, these children are permanently sterilized.[26], [32] Cross-sex hormones also put these youth at an increased risk of heart attacks, stroke, diabetes, blood clots, cancer, and other diseases across their lifespan.[26], [33] 

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Some health professionals insist these harms must be accepted because gender dysphoric youth are at significantly higher risk for committing suicide, and social affirmation, blockers, hormones, and surgeries prevent suicide. Both claims are false. Suicide risk among trans-identifying youth is similar to the elevated suicide rates among other at-risk youth. Based upon data from the United Kingdom’s Tavistok Gender Identity Clinic, Oxford sociologist Dr. Michael Biggs has reported that being trans-identified increases suicide risk by a factor of thirteen. He notes that this elevated risk, while concerning, is less than or within range of the suicide risk associated with other disorders: anorexia increases suicide risk by a factor of eighteen; depression multiplies one’s risk by a factor of twenty, and autism raises one’s suicide risk by a factor of eight. Additionally, anorexia, depression, autism, and other conditions pre-disposing to suicide nearly always coincide with gender dysphoria, causing some to question whether suicidality among gender dysphoric youth is due to comorbid psychological illnesses.[34] A recent ground-breaking study out of Finland has now confirmed this. The study authors are four Finnish child psychiatrists who pioneered gender-affirming treatment of gender dysphoric minors in their country. They sought to examine all-cause and suicide mortalities in gender-referred adolescents and the impact of psychiatric morbidity on mortality. They did this by comparing the all-cause and suicide mortalities among a Finnish nationwide cohort of all adolescents and young adults who contacted specialized gender identity services in Finland from 1996–2019 (n=2083) with the all-cause and suicide mortalities of 16,643 matched controls. The researchers found that when specialist-level psychiatric treatment was controlled for, neither all-cause nor suicide mortality differed between the two groups. The investigators concluded that gender dysphoria does not predict suicide mortality in gender-referred adolescents. Instead, they identified the main predictor of suicide mortality among gender dysphoric youth as psychiatric morbidity and found that gender reassignment does not have an impact on suicide risk [emphasis added].[35] In short, suicide prevention for youth with gender dysphoria should be the same as it is for all other at-risk youth; namely, individual and family counseling to identify and resolve underlying issues and psychiatric medications when indicated.

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The vast majority of youth with gender dysphoria are recognized as suffering from unresolved traumas, mental illness, and/or neurodiversity. Ethical medical treatments restore normal development, health, and function and relieve suffering. Social transition, puberty blockers, cross-sex hormones, and cross-sex surgeries are unethical because they do not mitigate or heal the comorbid conditions of those with gender dysphoria, nor do they improve mental health or prevent suicide in this population. Instead, these transgender-affirming interventions disrupt normal health, function, and development, causing irreparable damage, including permanent sterility, bone loss, cardiovascular disease, elevated cancer risk, and other potential disease states. Sadly, many minors, young adults and their parents, as well as school, church, and government leaders, are being led astray by a vocal sector of the medical establishment driven by a deadly ideology and economic opportunism. All people of good will must unite to end this grave medical scandal and uphold the right to optimal health for these vulnerable youths.