The Department of Health and Human Services (HHS) released what it called a “comprehensive review” of transgender care for children and teens on Thursday, calling for broader use of psychotherapy for young people with gender dysphoria rather than gender-affirming care.
The more than 400-page document details alleged harms from medical interventions for youth, including the use of puberty blockers, and alleged risks, such as infertility.
The “review of evidence and best practices report” is a response to a January executive order issued by President Donald Trump, saying the federal government would not “fund, sponsor, promote, assist or support” transition care for those under age 19.
“Our duty is to protect our nation’s children — not expose them to unproven and irreversible medical interventions,” Dr. Jay Bhattacharya, director of the National Institutes of Health, said in a statement on Thursday. “We must follow the gold standard of science, not activist agendas.”
Gender-affirming care is supported by multiple major medical organizations. It can range from allowing a child to pick their pronouns to treatments typically prescribed for older teens. Studies show treatments are generally safe and that care has a positive impact on mental health, which psychotherapy alone cannot provide, experts said.
“Requiring that somebody [go] through a prescribed course of therapy can be misused by governments to try to essentially block access to care,” Dr. Dan Karasic, professor emeritus of psychiatry at the University of California San Francisco Weill Institute for Neurosciences, told ABC News. “There just isn’t evidence that psychotherapy resolves gender dysphoria.”
President Donald Trump holds an executive order relating to education in the Oval Office of the White House, April 23, 2025.
Alex Brandon/AP
Safety of puberty blockers, hormone therapies
One of the most common treatments in gender-affirming care is the use of puberty blockers, which are used to delay the onset of puberty among transgender and gender-diverse youth.
The report claimed its review of studies found low evidence that puberty blockers are safe or that they improved mental health among children with gender dysphoria, and “high certainty evidence” that they often cause infertility.
The reported also stated, “Low certainty evidence suggests that puberty blockers may compromise bone health.”
However, studies have shown that adults who used puberty blockers in the past experienced menstrual cycles, childbirth and miscarriages at similar rates to those of the general population.
Dr. Morissa Ladinsky, a clinical professor in pediatrics at Stanford University in California, said puberty blockers have been used as a treatment for more than 30 years, primarily for a condition called CPP, or central precocious puberty, which is when puberty begins too early.
“These medications are immensely well-studied,” she told ABC News. “The long-term effects of puberty-pausing medications, when used in children, for temporary periods of time, do function as a completely reversible pause button.”
She said side effects related to sexual function or bone density are usually seen among adults, who may take the medications for prostate cancer in order to reduce testosterone, or endometriosis.
The HHS report also discussed cross-sex hormones, more commonly known as hormone therapies, claiming there is “high certainty evidence” that hormone therapies have “physiological effects” and that many studies were “not specifically designed to capture the full range of long-term outcomes.”
Although hormones can carry side effects, like any medicine, they can greatly improve the mental health of those with gender dysphoria, studies show.
Signage for the Department of Health and Human Services (HHS) headquarters is seen, April 2, 2025, in Washington, D.C.
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Ladinsky said hormone therapies are often used with older adolescents who have had sustained gender dysphoria over a long period of time.
Hormone therapies “are all used and have been used in pediatric and adolescent medicine, for a long, long, long time,” she said. “Any person who’s ever used combination birth control pills has taken oral estrogen. So, it’s not that these medicines are unique, experimental, pulled off a shelf. They’re standard pharmacology in the practice of medicine.”
Controversy around surgeries
The review said it found three studies on surgeries for children or adolescents with gender dysphoria “with most considering mastectomy only.”
Gender-affirming mastectomy, known colloquially as “top surgery,” is a surgical procedure that removes breast tissue to create a more masculine-looking chest.
The report said authors found low certainty of evidence on the effects of gender-affirming surgeries on adolescents including suicidality, depression, asexual function, quality of life and regret.
Ladinsky said there are no gender-affirming genital surgeries that occur on minors and no other gender-affirming surgeries being performed on young children.
“There is a very small group of trans-masculine older teens, meaning 17-ish, 18, who — in our evidence-based, guideline-driven standard of care — does allow for a tiny group of these older trans-masculine teens with overwhelming and sustained gender dysphoria to have masculinizing chest surgery,” she said.
Ladinsky continued, “That is very, very rare and that procedure can only be done with long periods of oversight around gender dysphoria with doctors, immense parental consent and professional endorsement by those caring for the young person.”
HHS advocates for psychotherapy
The HHS report advocates for the use of psychotherapy as a treatment for children and adolescents with gender dysphoria.
“Psychotherapy is a noninvasive alternative to endocrine and surgical interventions for the treatment of pediatric gender dysphoria,” the report stated. “Systematic reviews of evidence have found no evidence of adverse effects of psychotherapy in this context.”
Dr. Klara Widrig protests with fellow activists during the Trans Day Of Visibility rally on the National Mall, March 31, 2025, in Washington, D.C.
Kayla Bartkowski/Getty Images
Karasic said certain kinds of psychotherapy can be used to treat symptoms of anxiety and depression among both cisgender and transgender individuals, but psychotherapy should not be considered a substitute for gender-affirming care.
“There’s absolutely no evidence that psychotherapy is a substitute for those people who need medical care,” he told ABC News. “There’s substantial evidence for the benefits of [gender-affirming] care for minors, and that’s why all mainstream medical and mental health groups support this versus no evidence of psychotherapy being a substitute.”
Karasic said psychotherapy is not bad, but rather that it has its place and, very often, children and teenagers receive psychotherapy along with medical intervention.
“If people are proposing the availability of therapy for people who need it, I think everyone would agree with that,” he said. “But when people are saying that medical intervention should not be provided because therapy can be used instead, that’s wrong. There’s just no evidence to support that.”
Response from the medical community
The American Academy of Pediatrics released a statement on Thursday saying it is “deeply alarmed” by the HHS 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,” the statement read in part. “This report misrepresents the current medical consensus and fails to reflect the realities of pediatric care.”
AAP also released a statement with several groups, including the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American College of Physicians, the American Osteopathic Association and the American Psychiatric Association, opposing an infringement on medical care.
“Our organizations have consistently opposed any legislation, regulation or executive action that interferes in the confidential relationship between a patient and their physician or undermines the provision of evidence-based standards of patient care and physician training and education,” the statement, released on Thursday, read. “Patients must must be able to discuss health issues with their trusted physician to determine together what care is best for them.”
More than 500 anti-LGBTQ+ bills have been introduced throughout the 2024 legislative session, according to the American Civil Liberties Union.
Ladinsky said these bills are harmful and they don’t resolve gender dysphoria for anyone.
“If government-sanctioned, blatant misinformation is utilized to make policy decisions that affect millions of Americans, we are opening a Pandora’s box to greatly diminish the health of all people, rather than elevating it,” she said. “The other thing important is that we know from 25 states that have rendered illegal elements of this care, it hasn’t made any children of trans identity no longer trans.”
