Gender-affirming care refers to the medical treatment of children and teenagers with gender dysphoria using puberty blockers and cross-sex hormones, sometimes followed by surgery, designed to make patients more closely resemble the opposite sex.
Puberty blockers act on the brain to stop the release of sex hormones such as testosterone in males and oestrogen in females. When given to children with gender dysphoria, the drugs are intended both to relieve psychological distress and to buy patients "time to think"—pausing puberty while they consider whether to proceed with cross-sex hormones or surgery.
Data from the Tavistock and Portman NHS Trust, which ran the largest gender clinic in England and Wales until it was shut down in 2024, suggest that over 90% of children prescribed puberty blockers go on to take cross-sex hormones (testosterone for females, oestrogen for males). If those hormones are prescribed early enough in puberty, they can cause irreversible sterility. The Tavistock data also indicate that 34% of children on puberty blockers saw their mental health worsen, while 29% saw it improve.
A study published in 2020 found significant decreases in bone-mineral density in children given puberty blockers. Reports from patients prescribed the medication Lupron for precocious puberty describe serious joint and skeletal problems in young adulthood. Animal trials suggest that blocking sex-hormone production may hinder brain development in adolescence. One human study of 25 female patients with precocious puberty found an average IQ decline of seven points over three years, though other studies have not replicated this finding.
In 2024 Hilary Cass, a British paediatrician, published an influential review of gender medicine for the NHS. Dr Cass concluded that most of the science underlying the prescription of puberty blockers and cross-sex hormones to teenagers was "remarkably weak". She recommended that doctors and scientists gather better data through clinical trials. Following the report, the NHS forbade the prescription of puberty blockers except as part of a clinical trial.
On November 22nd 2025 British regulators approved PATHWAYS, a clinical trial of puberty blockers led by Emily Simonoff, a psychiatrist at King's College London. The trial aims to recruit 226 children between the ages of ten and 16. Its results would be read around the world: child gender medicine is controversial and several countries have imposed restrictions (on November 24th 2025 New Zealand became the latest to do so).
Unlike many clinical trials, PATHWAYS will have no placebo arm: every child will receive puberty blockers, either immediately or after a year. All participants will also receive psychological therapies. Follow-up will last just two and a half years. Critics, including Hannah Ryan, a doctor with experience in analysing clinical evidence, argue that the design risks making it hard to discern the effects of the drugs. If a trial is unlikely to yield reliable information, they say, it is not ethical.
Gender dysphoria often resolves with time. Previous studies have raised the possibility that, rather than buying time to think, puberty blockers may propel children into hormones and surgery. There are worries about bone health and fertility. Animal studies hint at long-term cognitive impairments. Critics say data could be collected in less risky ways: thousands of people have already been given puberty blockers and their health records could be studied. An American report published in November 2025 suggests more animal studies.
Wes Streeting, Britain's health secretary, maintains that the lack of good evidence makes the trial vital. Kemi Badenoch, leader of the opposition Conservative Party, considers it unethical. Opponents have said they will seek a judicial review to halt the trial.
The World Professional Association for Transgender Health, which writes guidelines for the field, disagrees with Dr Cass on the lack of evidence and argues it is unethical to limit puberty blockers to clinical-trial participants. Alternatives to a clinical trial include further animal studies and "data-linkage" studies examining the health records of adults who were given puberty blockers as teenagers. A previous attempt at such a study was thwarted when British gender clinics refused to co-operate.
In January 2025 Donald Trump signed an executive order entitled "Protecting Children from Chemical and Surgical Mutilation", instructing federally run insurance programmes to exclude coverage of transition-related treatment for minors and commissioning the Department of Health and Human Services (HHS) to review the literature. The ban on federal funding was later blocked by a judge, but the review was published on May 1st 2025.
The report, more than 400 pages long with a 173-page appendix, was structured in five sections: history, a review of existing evidence, clinical realities in American gender clinics, ethics and the importance of psychotherapy. Chapters were subject to peer review.
Its summary concluded: "The evidence for benefit of paediatric medical transition is very uncertain, while the evidence for harm is less uncertain." It found the overall quality of evidence on the effects of intervention to be "very low", based on a review of 17 previous systematic reviews. The report said the risks include sterility, sexual dysfunction, impaired bone density, adverse cognitive impacts, psychiatric disorders, surgical complications and regret. Claims that distressed children who do not transition face greater risk of suicide "are not supported by the evidence".
The ethics chapter was described as perhaps the deepest bioethical analysis of the issue yet published. Jonathan Moreno, a professor emeritus at the University of Pennsylvania and an adviser to Barack Obama's bioethics commission, told the British Medical Journal that the report cited reputable bioethical texts and presented a "plausible" analysis.
The TransYouth Project, led by Kristina Olson (now at Princeton University), is the single largest and most successful longitudinal effort to track early-transitioning young people in the world. Dr Olson received a MacArthur genius grant in 2018 for the work. The study recruited hundreds of children who had socially transitioned—living in a new gender without medical intervention—as well as their siblings and an unrelated comparison group.
Results published in the Monographs of the Society for Research in Child Development in July 2025 found that 82% of children who transitioned young (at an average age of six and a half) maintained a stable gender identity over a follow-up period averaging seven years. The remaining 18% experienced at least one identity change, either re-identifying with their natal sex or coming out as non-binary. An earlier study of the same cohort, published in Pediatrics in 2022, had found only 7% instability over five years, suggesting that with time a significant number of children develop different feelings about their gender identities. The cohort was last surveyed at age 15.
The study also found that 23% of female siblings of trans-identifying children became transgender-identified during the study period—far higher than the 9-10% rate among male siblings or among unrelated children in the comparison group. The majority of young people identifying as transgender in recent years, often 60% or more according to studies, were born female. All these figures are far higher than population-based estimates of the trans population, which have historically hovered at around 1%.
Between 2016 and 2020, 3,215 elective mastectomies were carried out on 12- to 18-year-olds as part of gender-transition treatment, according to the Journal of the American Medical Association; the true number is likely higher. On January 30th 2026 a New York jury awarded $2m to Fox Varian, a detransitioner—$1.6m for past and future pain and $400,000 for future medical costs. Ms Varian had undergone a double mastectomy at the age of 16 in December 2019 after her psychologist allegedly warned her mother that she was in danger of committing suicide without the surgery. Her mental health worsened after the procedure, and by 2022 she had decided to detransition. It was the first malpractice lawsuit by a detransitioner to come before an American jury. More than two dozen other detransitioners have filed lawsuits; observers believe total damages could run into hundreds of millions of dollars.
On February 3rd 2026 the American Society of Plastic Surgeons (ASPS) became the first American medical association to come out against gender-related surgery for patients under 19, citing "limitations in study quality, consistency and follow-up, alongside emerging evidence of treatment complications and potential harms". It also said there was "insufficient evidence" that the benefits outweigh the harms of prescribing cross-sex hormones or puberty blockers to adolescents. The following day the American Medical Association, representing more than 250,000 physicians, agreed that "surgical interventions in minors should be generally deferred to adulthood". The American Academy of Paediatrics continues to back adolescent transitioning.
The World Professional Association of Transgender Health (WPATH) writes guidelines embedded in American health care, though the group does not require members to be medical professionals. The HHS report claimed that WPATH "suppressed systematic reviews its leaders believed would undermine its favoured treatment approach" during the development of its latest standards of care, promoting the idea that children could consent to treatment and that treatment was beneficial even though its own evidence could not support either assertion.
Major American medical organisations, including the American Academy of Paediatrics and the American Medical Association, follow WPATH's "gender-affirming" approach. The HHS report traced how this impression of medical consensus came about through "blind delegation of authority" to WPATH—a chain of trust the report said was broken when WPATH chose to suppress evidence. In Britain, the left-of-centre Labour government has committed to implementing the Cass Review in full.
New York is real. The rest is done with mirrors.