The U.S. Department of Health and Human Services (HHS) released a highly anticipated literature review on Thursday recommending that medical providers prioritize behavioral therapy when treating patients under 19 with gender dysphoria, and broadly rejecting gender-affirming care options such as hormone therapy, puberty blockers, and surgery. The report, which makes no policy recommendations and is not clinical guidance, clearly diverges from the standards issued by the World Professional Association for Transgender Health (WPATH), a nonprofit dedicated to evidence-based research on transgender medicine.

The American Medical Association, the American Psychological Association, and the American Academy of Pediatrics have all independently endorsed WPATH's recommendations, which advocate a combined social, psychological, behavioral, and medical approach to treating gender dysphoria. However, President Donald Trump has repeatedly condemned the organization, calling it "politically motivated."

In January, President Trump issued an executive order requiring the federal government to stop funding medical institutions that provide gender-affirming care to minors and directing HHS to conduct its own study on best treatment practices for gender dysphoria in those under 19. The resulting report, 409 pages long, claims that WPATH wrongly promotes a consensus on how to treat adolescents struggling with gender identity and "suppresses dissent and stifles debate."

HHS heavily cites a controversial 2024 U.K. report—known as the "Cass Review"—to provide a counter-narrative. The Cass Review concluded that long-term evidence supporting the use of puberty blockers and hormone therapy in adolescents is insufficient and that these treatments should only be used for experimental purposes. The report has been sharply criticized for relying on low-quality studies, with skeptics saying its author, Hilary Cass, "may" have excluded relevant research. Cass stated she excluded some studies for methodological reasons but sometimes did not specify the reasons for exclusion.

The HHS review also includes testimony from five whistleblowers who worked in clinics and allegedly witnessed gender-affirming treatments causing harm to patients. The agency stated that the review overall shows gender-affirming care poses "significant risks" to patients, while the "evidence for benefit is very weak."

Instead, HHS advocates for increased use of behavioral therapy or "exploratory" therapy, though the agency never clearly defines these terms. The report attempts to distance its recommendations from the term "conversion therapy"—which, according to data from the Human Rights Campaign, has been restricted or banned by legislation in 20 U.S. states, Puerto Rico, and Washington, D.C. The report states: "Research on psychological treatments for gender dysphoria in children and adolescents is scarce, partly because such approaches have been wrongly characterized as 'conversion therapy.' Psychotherapy is a non-invasive alternative to endocrine and surgical interventions for treating pediatric gender dysphoria."

However, a name may just be a name. Arjee Restar, a social and epidemiologist at Yale University, said via email: "The report's framing of psychotherapy as an alternative to medical affirmation—especially in ways that delay or impede access to qualified gender-affirming care providers—echoes the ideology and pathologizing practices behind past conversion therapy efforts."

Accusations of overreach

National Institutes of Health Director Jay Bhattacharya praised the report in a statement Thursday: "Our job is to protect the nation's children—not to expose them to unproven and irreversible medical interventions. We must follow the gold standard of science, not radical agendas."

However, some doctors, medical researchers, and analysts were quick to point out that HHS is precisely attempting to place its own agenda above scientific consensus. Kellan Baker, executive director of the Health Research and Policy Institute at the Whitman-Walker Health Institute, said in an email: "This report is pure politics disguised as science. Its ultimate goal is to impose a political agenda to replace science and insert the federal government where it does not belong—between medical providers and the families and patients they care for."

Experts interviewed expressed dissatisfaction with the use of anecdotes to guide policy recommendations and with HHS's refusal to disclose the report's authors. In a press release, the agency said it withheld author names to "preserve the integrity of the process." Meredith McNamara, assistant professor of pediatrics at Yale School of Medicine and co-founder of the Integrity Project, said: "That's complete nonsense. That's not how scientific integrity works. If people aren't willing to put their names on it, then it shouldn't be taken seriously." McNamara also noted that the agency's claim of lacking long-term studies on gender-affirming care conflicts with the medical community's routine reliance on observational studies to advance care practices.

Susan Kressly, president of the American Academy of Pediatrics, echoed this view in a statement shared Thursday, saying she was "deeply alarmed" by the report. Kressly stated: "For such an analysis to be credible, it must consider the totality of available data and the full range of clinical outcomes, rather than relying on selective opinions and narrow datasets. This report misrepresents the current medical consensus and fails to reflect the reality of pediatric care."

However, Stanley Goldfarb, chairman of the organization "Do No Harm," fully endorsed the report, saying it "rightly exposes the many serious risks of medical transition in young people." Goldfarb stated: "It is now clearer than ever that we must end this misguided practice and replace it with evidence-based treatments to help gender-confused children."

The report is part of a series of escalating actions by the administration to restrict transgender youth's access to healthcare and related treatment research. Earlier this week, Trump said he had tasked the Department of Justice with investigating parties that facilitate gender-affirming care for minors, including service providers and companies that "mislead the public about the long-term side effects of treatments" under the Food, Drug, and Cosmetic Act. The administration has also created a website for people to report gender-affirming care and has proposed a private right of action allowing children who received gender-affirming care or their families to sue for damages.

Broader consequences may follow

Trump's focus on transgender individuals is extraordinary. Although the administration repeatedly claims that "many" children are diagnosed with gender dysphoria, in reality only about 1% of children receive this diagnosis, and only a small fraction of them receive treatment, according to a research letter published in January in JAMA Pediatrics. However, the president is not the only one seeking to reduce transgender youth's access to care. According to tracking data from the Human Rights Campaign, 26 states nationwide have enacted gender-affirming care bans. Several of these bans are being challenged in court, including Tennessee's ban, which awaits a U.S. Supreme Court ruling this summer.

If the Supreme Court declines to issue a sweeping ruling—similar to its piecemeal approach to state abortion bans—this literature review could appear in courtroom debates over healthcare access. Currently, plaintiffs seeking to preserve healthcare access for adolescents commonly cite WPATH guidelines. However, many conservative-leaning judges have shown caution in accepting these recommendations. For example, Chief Judge Jeffrey Sutton of the Sixth Circuit Court of Appeals wrote in the majority opinion upholding Tennessee's ban that medical protocols are "constantly evolving." He said that despite hearing doctors cite WPATH guidelines and praise the benefits of hormone therapy, it was difficult to define clear boundaries of "medically necessary care."

Now, Thursday's literature review devotes 30 pages to discrediting WPATH. If state attorneys general submit it as evidence, the guidelines could provide judges with more ammunition to dismiss the medical community's recommendations on gender-affirming care. Suzanne Goldberg, a law professor at Columbia Law School and director of the Sexuality and Gender Law Clinic, said: "If this report is submitted, plaintiffs seeking to protect access to gender-affirming care will have the opportunity to criticize its claims, credibility, and methodology, including the report's heavy reliance on the U.K.'s Cass Review." She noted that courts have a duty to examine the evidence presented.

Nevertheless, providers seeking to offer gender-affirming care to adolescents are facing an increasingly hostile environment. Under Trump's crackdown, several providers have suspended services, including Children's Healthcare of Atlanta, Penn State Health, UPMC, and Lurie Children's Hospital in Chicago. McNamara said the administration's guidance on medical practice is unprecedented. She said: "If you look at any other democracy that is collapsing, one of the first things that starts happening is the government begins making healthcare decisions for its people through policy. This feels extremely alarming and unusual, and we cannot forget that."