American advocates for youth gender medicine have insisted for years that overwhelming evidence favors providing gender dysphoric youth with puberty blockers, hormones and, in the case of biological females, surgery to remove their breasts.
It didn’t matter that the number of kids showing up at gender clinics had soared and were more likely to have complex mental health conditions than those who had come to clinics in years earlier, complicating diagnosis. Advocates and health care organizations just dug in. As a billboard truck used by the L.G.B.T.Q. advocacy group GLAAD proclaimed in 2023, “The science is settled.” The Human Rights Campaign says on its website that “the safety and efficacy of gender-affirming care for transgender and nonbinary youth and adults is clear.” Elsewhere, these and other groups, like the American Civil Liberties Union, referred to these treatments as “medically necessary,” “lifesaving” and “evidence-based.”
The reason these advocates were able to make such strong statements is that for years, the most important professional medical and mental health organizations in the country had been singing a similar tune: “The science” was supposedly codified in documents published by these organizations. As GLAAD puts it on its website, “Every major medical association supports health care for transgender people and youth as safe and lifesaving.”
But something confounding has happened in the last few weeks: Cracks have appeared in the supposed wall of consensus.
After expressing concerns about the evidence base in 2024, on Feb. 3, the American Society of Plastic Surgeons became the first major American medical group to publicly question youth gender medicine since its widespread adoption. The organization published a nine-page “position statement” advising its members against any gender-related surgeries before age 19 and noting that “there are currently no validated methods” for determining whether youth gender dysphoria will resolve without medical treatment. (The document also acknowledged a similar level of uncertainty surrounding blockers and hormones, though that’s less directly relevant to the practice of plastic surgeons.)
The next day, the American Medical Association — which has long approved of such procedures — announced that “in the absence of clear evidence, the A.M.A. agrees with A.S.P.S. that surgical interventions in minors should be generally deferred to adulthood.”
These statements were released days after a woman named Fox Varian became the first person to win a malpractice case after undergoing gender transition care and later regretting it. Ms. Varian and her lawyer argued that her psychologist and plastic surgeon in suburban New York, despite her serious mental health problems and apparent ambivalence over her transgender identity, failed to safeguard her by going forward with a double mastectomy when she was 16. (Many gender medicine practitioners and advocates believe that to carefully scrutinize or even explore claims of a transgender identity is to engage in de facto conversion therapy.) The jury’s $2 million award will most likely give pause to hospitals and clinics that continue to provide these treatments without substantial guardrails.
The science doesn’t seem so settled after all, and it’s important to understand what happened here. The approach of left-of-center Americans and our institutions — to assume that when a scientific organization releases a “policy statement” on a hot-button issue, that the policy statement must be accurate — is a deeply naïve understanding of science, human nature and politics, and how they intersect.
At a time when more and more Americans are turning away from expert authority in favor of YouTube quacks and their ilk — and when our own government is pushing scientifically baseless policies on childhood vaccination and climate change — it’s vital that the organizations that represent mainstream science be open, honest and transparent about politically charged issues. If they aren’t, there’s simply no good reason to trust them.
The most striking finding of the Cass review, a 2024 British inquiry that found “remarkably weak” evidence to back up the practice of youth gender medicine, was the shoddy quality of the professional guidelines for this treatment.
Researchers at the University of York, who provided underlying work for the Cass review, found that rather than being linked to careful, independent evaluations of the evidence, these guidelines relied heavily on other organizations’ guidelines. The authors wrote that this “may explain why there has until recently been an apparent consensus on key areas of practice for which evidence remains lacking.”
A 2018 policy statement by the American Academy of Pediatrics provides a useful example of how these documents can go wrong. At one point, it argues that children who say they are trans “know their gender as clearly and as consistently as their developmentally equivalent peers,” an extreme exaggeration of what we know about this population. (A single study is cited.) The document also criticizes the “outdated approach in which a child’s gender-diverse assertions are held as ‘possibly true’ until an arbitrary age” — the A.A.P. was instructing clinicians to take 4- and 5-year-olds’ claims about their gender identities as certainly true. It’s understandable why the Cass reviewers scored this policy statement so abysmally, giving it 12 out of 100 possible points on “rigor of development” and six out of 100 on “applicability.”
Policy statements like this one can reflect the complex and opaque internal politics of an organization, rather than dispassionate scientific analysis. The journalist Aaron Sibarium’s reporting strongly suggests that a small group of A.A.P. members, many of whom were themselves youth gender medicine providers, played a disproportionate role in developing these guidelines.
Dr. Julia Mason, a 30-year member of the organization, wrote in The Wall Street Journal, with the Manhattan Institute’s Leor Sapir, that the A.A.P. deferred to activist-clinicians and stonewalled the critics’ demands for a more rigorous approach. Dr. Sarah Palmer, an Indiana-based pediatrician, told me she recently left the A.A.P. after nearly 30 years because of this issue. “I’ve tried to engage and be a member and pay that huge fee every year,” she said. “They just stopped answering any questions.” This is unfortunate given that, as critics have noted, in many cases the A.A.P. document’s footnotes don’t even support the claims being made in the text.
The shakiness of the guidelines didn’t matter, though — they were cited numerous times in news accounts and court documents as evidence that the most important pediatric association in the country supported youth medical transition.
In 2020, Republican-led states began pushing in earnest to tightly restrict or ban youth gender medicine. In response, the professional organizations — including the A.M.A., the A.A.P. and the American Psychological Association — wrote a flurry of letters to legislators, amicus briefs and sciencey-sounding documents opposing the bans. These documents routinely exaggerated the evidence base for the treatments in question. There was more talk of consensus: “Every major medical association in the United States recognizes the medical necessity of transition-related care for improving the physical and mental health of transgender people,” explained the A.M.A. in a letter from 2021.
During this same period, a sea change occurred in Europe. Finland, Sweden and Britain conducted systematic evidence reviews of youth gender medicine — a much more transparent and regimented process designed to attenuate the influence of human bias. Every such review revealed deep uncertainty about the evidence base, and as a result the countries that conducted the reviews began more tightly regulating youth gender medicine. (Denmark has since followed suit, and there are some signs France and Norway may as well.) Which science, then, should be trusted? The confident American professional organizations or the skeptical European health care systems? What about when even the professional organizations start to schism?
I’ve been covering this controversy for about a decade from a left-of-center perspective, and I’ve found that anyone who questions these treatments, even mildly, is invariably accused of bigotry. It would be shocking if the professional organizations chiming in on these issues — which, like all such organizations, exist in part to increase the esteem of their members and to enhance their own influence — were immune from such influences. And now that the political winds have shifted radically, with the Trump administration launching an all-out assault on both the practice of and research into youth gender medicine, it seems some of them are realizing they would benefit from appearing a bit more moderate.
Perhaps I’m being unfair. But it’s impossible to know, because these organizations are quite opaque about the processes that give rise to their public statements. They’ve tried to have it both ways: They’ve presented themselves as representing “the science” while sometimes violating science’s traditional norms of transparency and open debate. (Neither the A.A.P. nor the A.M.A. would grant me an interview. The American Psychological Association responded to some of the questions I sent the organization via email.)
The A.P.A. presents a particularly striking case of why transparency is important. In 2024, it published what it touted as a “groundbreaking policy supporting transgender, gender diverse, nonbinary individuals” that was specifically geared at fighting “misinformation” on that subject. But when I reached out to the group this month, it pointed me to a different document, a letter written by the group’s chief advocacy officer, Katherine McGuire, in September in response to a Federal Trade Commission request for comment on youth gender medicine.
The documents, separated by about a year and a half (and, perhaps as significantly, one presidential election), straightforwardly contradict each other. The A.P.A. in 2024 argued that there is a “comprehensive body of psychological and medical research supporting the positive impact of gender-affirming treatments” for individuals “across the life span.” But in 2025, the group argued that “psychologists do not make broad claims about treatment effectiveness.”
In 2024, the A.P.A. criticized those “mischaracterizing gender dysphoria as a manifestation of traumatic stress or neurodivergence.” In 2025, it cautioned that gender dysphoria diagnoses could be the result of “trauma-related presentations” rather than a trans identity, and noted that “co-occurring mental health or neurodevelopmental conditions (e.g., depression, anxiety, autism spectrum disorder) … may complicate or be mistaken for gender dysphoria.” It seems undeniable that the 2025 A.P.A. published what the 2024 A.P. A considered to be “misinformation.” (“The 2024 policy statement and the 2025 F.T.C. letter are consistent,” said Ms. McGuire in an email, and “both documents reflect A.P.A.’s consistent commitment to evidence-based psychological care.”)
Along those same lines, how did the American Medical Association go from arguing that “forgoing gender-affirming care can have tragic consequences” for “pediatric patients” in its 2021 letter to its present stance that one such treatment, surgery, should be delayed — potentially for many years — as a general matter of course?
If, as I suspect, political forces are the culprit, that would lead to an inescapable conclusion: You cannot automatically trust what these organizations say at a given moment. Not unless they provide a lot more information about their decision-making processes.
Should we “trust the science”? Sure, in theory — but only when the science in question has earned our trust through transparency and rigor.
Jesse Singal is writing a book about the debate over youth gender medicine in the United States and writes the newsletter Singal-Minded.
Source images by Javier Zayas Photography, Solskin/Getty Images.
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