As physicians, together with nurses, psychotherapists and behavioral health clinicians, other health professionals, scientists, researchers, and public health and policy professionals, we have serious concerns about the physical and mental health effects of the current protocols promoted for the care of children and adolescents in the United States who express discomfort with their biological sex.

We affirm:

1. Sex is a dimorphic, innate trait defined in relation to an organism’s biological role in reproduction. In humans, primary sex determination occurs at fertilization and is directed by a complement of sex determining genes on the X and Y chromosomes.  This genetic signature is present in every nucleated somatic cell in the body and is not altered by drugs or surgical interventions
2. Consideration of these innate differences is critical to the practice of good medicine and to the development of sound public policy for children and adults alike.
3. Gender ideology, the view that sex (male and female) is inadequate and that humans need to be further categorized based on an individual’s thoughts and feelings described as “gender identity” or “gender expression”, does not accommodate the reality of these innate sex differences. This leads to the inaccurate view that children can be born in the wrong body.  Gender ideology seeks to affirm thoughts, feelings and beliefs, with puberty blockers, hormones, and surgeries that harm healthy bodies, rather than affirm biological reality.
4. Medical decision making should not be based upon an individual’s thoughts and feelings, as in “gender identity” or “gender expression”, but rather should be based upon an individual’s biological sex. Medical decision making should respect biological reality and the dignity of the person by compassionately addressing the whole person.

We recognize:

1. Most children and adolescents whose thoughts and feelings do not align with their biological sex will resolve those mental incongruencies after experiencing the normal developmental process of puberty.

• • Desistance is the norm without affirmation as documented by Zucker in his article “The Myth of Peristence”. (1)
    Zucker, KJ. The myth of persistence: Response to “A critical commentary on follow-up studies and ‘desistance’ theories about transgender and gender nonconforming children” by Temple Newhook et al. International Journal of Transgenderism. 2018: 19(2), 231–245. Published online May 29, 2018.http://doi.org/10.1080/15532739.2018.1468293 [1]
  • In the “largest sample to date of boys clinic-referred for gender dysphoria,” there was a desistance rate of 87.8%. (2)
    Singh D, Bradley SJ and Zucker KJ. A Follow-Up Study of Boys With Gender Identity Disorder. Front Psychiatry. 2021;12:632784. doi: 10.3389/fpsyt.2021.632784
  • The pro-affirmation Endocrine Society Guidelines (2017) admit: “…the GD/gender incongruence of a minority of prepubertal children appears to persist in adolescence.” (3)
    Hembree, W., Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guideline J Clin Endocrinol Metab. 2017; 102:1–35.
  • A longitudinal study from the University of Groningen in the Netherlands followed 2772 adolescents (recruited from a psychiatric clinic) from age 11 years through 22 – 26 years. “In early adolescence 11% of participants reported gender non- contentedness. The prevalence decreased with age and was 4% at the last follow-up (around age 26).” Even in this psychiatric patient study group for which interventions were not addressed, but “gender affirmation” is most likely, gender non-contentedness (essentially gender noncongruence) decreased substantially from early adolescence to young adulthood.(4)
    Rawee P, Rosmalen JGM, Kalverdiijk L and Burke SM. Development of gender non-contentedness during adolescence and early adulthood. Archives of Sexual Behavior. 2024; https://doi.org/10.1007/s10508-024-02817-5

1. Responsible informed consent is not possible in light of extremely limited long-term follow-up studies of interventions, and the immature, often impulsive, nature of the adolescent brain. The adolescent brain’s prefrontal cortex is immature and is limited in its ability to strategize, problem solve and make emotionally laden decisions that have life-long consequences.[2]
2. Sex-trait modification or “Gender affirming” clinics in the United States base their treatments upon the “Standards of Care” developed by the World Professional Association for Transgender Health (WPATH). However, the foundation of WPATH guidelines is demonstrably flawed and pediatric patients can be harmed when subjected to those protocols.

• The two Dutch studies that form the foundation for treatment guidelines as documented in the WPATH “Standards of Care” guidelines version 7 (SOC 7) had serious flaws.[3]
• These studies did show that the appearance of secondary sex characteristics in adolescents and young adults could be changed by hormonal and surgical interventions, but they failed to demonstrate meaningful long-term improvement in psychological well-being.
• Scientific concerns with these studies also include a lack of a control group, small sample sizes, significant numbers of patients lost to follow up, and the elimination of patients who experienced significant mental illness from entering the studies.
• It is concerning that the Dutch studies did not address complications and adverse outcome in the adolescent cohort that underwent transition. These complications included new onset diabetes, obesity and one death.[4]

1. There is now sufficient research to further demonstrate the failure of the WPATH, American Academy of Pediatrics and Endocrine Society protocols.

• The Cass Review was released on April 10, 2024, as an “independent review of gender identity services for children and young people”. The following points are from Cass’s final report:[5]
  • Commissioned by the National Health Service (NHS) England, and chaired by Dr. Hilary Cass, the 388-page report utilized systematic reviews, qualitative and quantitative research, as well as focus groups, roundtables and interviews with international clinicians and policy makers.
  • As part of the evaluation, they reviewed the research on social transition, puberty blockers, and cross-sex hormones.
  • Social transition
    • “The systematic review showed no clear evidence that social transition in childhood has any positive or negative mental health outcomes, and relatively weak evidence for any effect in adolescence.
    • However, those who had socially transitioned at an earlier age and/or prior to being seen in clinic were more likely to proceed to a medical pathway.”
• Puberty blockers
  • “The systematic review undertaken by the University of York found multiple studies demonstrating that puberty blockers exert their intended effect in suppressing puberty, and also that bone density is compromised during puberty suppression. However, no changes in gender dysphoria or body satisfaction were demonstrated [emphasis added].”
  • “There was insufficient/inconsistent evidence about the effects of puberty suppression on psychological or psychosocial wellbeing, cognitive development, cardio-metabolic risk or fertility.”
  • “Moreover, given that the vast majority of young people started on puberty blockers proceed from puberty blockers to masculinizing/ feminizing hormones, there is no evidence that puberty blockers buy time to think, and some concern that they may change the trajectory of psychosexual and gender identity development.”
• Cross-sex hormones
  • “The University of York carried out a systematic review of outcomes of masculinising/feminising hormones.” They concluded, “There is a lack of high-quality research assessing the outcomes of hormone interventions in adolescents with gender dysphoria/incongruence, and few studies that undertake long-term follow-up. No conclusions can be drawn about the effect on gender dysphoria, body satisfaction, psychosocial health, cognitive development, or fertility.”
  • “Uncertainty remains about the outcomes for height/growth, cardio-metabolic and bone health.”
  • The Cass Review further stated, “Assessing whether a hormone pathway is indicated is challenging. A formal diagnosis of gender dysphoria is frequently cited as a prerequisite for accessing hormone treatment. However, it is not reliably predictive of whether that young person will have longstanding gender incongruence in the future, or whether medical intervention will be the best option for them.”
• A 2024 German systematic review on the evidence for use of puberty blockers (PB) and cross-sex hormones (CSH) in minors with gender dysphoria (GD) also found “The available evidence on the use of PB and CSH in minors with GD is very limited and based on only a few studies with small numbers, and these studies have problematic methodology and quality. There also is a lack of adequate and meaningful long-term studies. Current evidence doesn’t suggest that GD symptoms and mental health significantly improve when PB or CSH are used in minors with GD.”[6] 

1. There are serious long-term risks associated with the use of social transition, puberty blockers, masculinizing or feminizing hormones, and surgeries, not the least of which is potential sterility.

• Youth who are socially affirmed are more likely to progress to using puberty blockers and cross-sex (masculinizing or feminizing) hormones.
  • “Social transition is associated with the persistence of gender dysphoria as a child progresses into adolescence.”[7]
  • “Gender social transition of prepubertal children will increase dramatically the rate of gender dysphoria persistence when compared to follow-up studies of children with gender dysphoria who did not receive this type of psychosocial intervention and, oddly enough, might be characterized as iatrogenic.”[8]
• Puberty blockers permanently disrupt physical, cognitive, emotional and social development.
  • Side effects listed in the Lupron package insert include emotional lability, worsening psychological illness, low bone density, impaired memory, and the rare side-effect of pseudotumor cerebri (brain swelling).[9]
  • A coalition of physicians and medical organizations from around the world submitted a petition to the Commissioner of the U.S. Food and Drug Administration requesting urgent action be taken to eliminate the off-label use of GnRH (growth hormone) agonists in children.[10]
• Testosterone use in females and estrogen use in males are associated with dangerous health risks across the lifespan including, but not limited to, cardiovascular disease, high blood pressure, heart attacks, blood clots, stroke, diabetes, and cancer.[xi]^,[12]
• Genital surgeries affect future fertility and reproduction.

1. A report from Environmental Progress released on March 4, 2024, entitled “The WPATH Files” revealed “widespread medical malpractice on children and vulnerable adults at global transgender healthcare authority.”[13]

• “The WPATH Files reveal that the organization does not meet the standards of evidence-based medicine, and members frequently discuss improvising treatments as they go along.”
• “Members are fully aware that children and adolescents cannot comprehend the lifelong consequences of ‘gender-affirming care’ and, in some cases due to poor health literacy, neither can their parents.”
• In addition, developmentally challenged and mentally ill individuals were being encouraged to “transition”, and treatments were often improvised.

1. Evidence-based medical research now demonstrates there is little to no benefit from any or all suggested “gender affirming” interventions for adolescents experiencing Gender Dysphoria. Social “affirmation”, puberty blockers, masculinizing or feminizing hormones, and surgeries, individually or in combination, do not appear to improve long-term mental health of the adolescents, including suicide risk.[14]
2. Psychotherapy for underlying mental health issues such as depression, anxiety, and autism, as well as prior emotional trauma or abuse should be the first line of treatment for these vulnerable children experiencing discomfort with their biological sex.
3. England, Scotland, Sweden, Denmark, and Finland have all recognized the scientific research demonstrating that the social, hormonal and surgical interventions are not only unhelpful but are harmful. So, these European countries have paused protocols and are instead focusing on evaluating and treating the underlying and preceding mental health concerns.
4. Other medical organizations are adhering to the evidence-based medicine documented in the Cass Review Final Report.

• The constitution of the National Health Service in England will be updated to state, “We are defining sex as biological sex.”[15]
• The European Society of Child and Adolescent Psychiatry issued a document titled “ESCAP statement on the care for children and adolescents with gender dysphoria: an urgent need for safeguarding clinical, scientific, and ethical standards.”
  • In this paper, they stated, “The standards of evidence-based medicine must ensure the best and safest possible care for each individual in this highly vulnerable group of children and adolescents. As such, ESCAP calls for healthcare providers not to promote experimental and unnecessarily invasive treatments with unproven psycho-social effects and, therefore, to adhere to the “primum-nil-nocere” (first, do no harm) principle”.[16]

1. Health care professionals around the world are also acknowledging the urgent need to protect children from harmful “gender-affirming” interventions.

• In a letter to the British newspaper, The Guardian, sixteen psychologists, some of whom worked at the Tavistock Center for Gender Identity Development Service, acknowledged the role clinical psychologists played in placing children on an “irreversible medical pathway that in most cases was inappropriate.”[17]
• In the United States, a group of psychiatrists, physicians and other health care workers wrote an open Letter to the American Psychiatric Association (APA), calling on the APA to explain why it glaringly ignored many scientific developments in gender-related care and to consider its responsibility to promote and protect patients’ safety, mental and physical health.[18]

1. Despite all the above evidence that gender affirming treatments are not only unhelpful, but are harmful, and despite the knowledge that the adolescent brain is immature, professional medical organizations in the United States continue to promote these interventions. Further, they state that legislation to protect children from harmful interventions is dangerous since it interferes with necessary medical care for children and adolescents.

• The American Psychological Association states it is the largest association of psychologists worldwide. The organization released a policy statement in February 2024 stating, “The APA opposes state bans on gender-affirming care, which are contrary to the principles of evidence-based healthcare, human rights, and social justice.”[19]
• The Endocrine Society responded to the Cass Review by reaffirming their stance. “We stand firm in our support of gender-affirming care…. NHS England’s recent report, the Cass Review, does not contain any new research that would contradict the recommendations made in our Clinical Practice Guideline on gender-affirming care.”[20]

• The American Academy of Pediatrics (AAP) Board of Directors in August 2023, voted to reaffirm their 2018 policy statement on gender-affirming care. They did decide to authorize a systematic review but only because they were concerned “about restrictions to access to health care with bans on gender-affirming care in more than 20 states.”[21]
  • Of note, Dr. Hilary Cass called out the AAP for “holding on to a position that is now demonstrated to be out of date by multiple systematic reviews.”[22]

In Conclusion

Therefore, given the recent research and the revelations of the harmful approach advocated by WPATH and its followers in the United States, we, the undersigned, call upon the medical professional organizations of the United States, including the American Academy of Pediatrics, the  Endocrine Society, the Pediatric Endocrine Society, American Medical Association, the American Psychological Association, and the American Academy of Child and Adolescent Psychiatry to follow the science and their European professional colleagues and immediately stop the promotion of social affirmation, puberty blockers, cross-sex hormones and surgeries for children and adolescents who experience distress over their biological sex.  Instead, these organizations should recommend comprehensive evaluations and therapies aimed at identifying and addressing underlying psychological co-morbidities and neurodiversity that often predispose to and accompany gender dysphoria. We also encourage the physicians who are members of these professional organizations to contact their leadership and urge them to adhere to the evidence-based research now available.

In the United States of America, on June 6, 2024, this declaration was authored and signed by the American College of Pediatricians and co-signed by:

Catholic Medical Association (USA)

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