Care, Not Controversy

In the current frenzy over trans rights, one of the most contentious issues is what kind of medical treatment is appropriate for young people who do not identify with their assigned gender. A lot of the debate centers around genderaffirmin g care, a term that is widely, often wildly misunderstood, in ways that make it difficult to talk honestly about how best to support youth at a critical time in their lives.

Medically, gender-affirming care refers to a range of interventions designed to support an individual’s gender identity. Those interventions include reversible treatments such as puberty blockers (which pause the physical changes of puberty) and hormone therapy (which helps align physical characteristics with gender identity). These treatments are guided by established clinical protocols and by decades of medical research. 

Yet as transgender people have increasingly become targets in political and cultural debates, gender-affirming care is often used without reference to its medical definition, stripped of the scientific context and standards of care that guide its use. An executive order issued by the White House in January, 2025, likened this type of care to “chemical and surgical mutilation.” Few other forms of routine and non-invasive healthcare have faced such intense scrutiny from those unfamiliar with their clinical foundations.

Opponents of gender-affirming care have capitalized on public confusion, using it to promote misinformation and to recast the historical and scientific record. In doing so, they sidestep the bioethical frameworks that help clinicians, families, and policymakers weigh the real-world complexities involved. 

Gender-affirming care is neither a new idea nor a radical ideology. Rather, it’s a meticulous, carefully developed form of healthcare for people who want to live happier lives on their own terms. If more people could see gender-affirming care for what it is, a lot of the anti-trans messaging would be more clearly exposed for the hatemongering that it is. 

The current model of gender affirming care for trans youth draws on more than a century of research into treatment and practices. The first known clinic to provide gender-affirming care was the Institute for Sexual Science, founded in Berlin in 1919 by German physician Magnus Hirschfeld. The institute offered a range of services—including counseling, hormone treatments, and some of the earliest gender-affirming surgeries—for people who today would be understood as transgender. It was a hub of research, education, and advocacy. But in 1933, just months after Adolf Hitler came to power, Nazi student groups ransacked the institute, burned its library in a public bonfire at Berlin’s Bebelplatz, and shut the clinic down.

After World War II, psychoanalysis rather than medical care became the dominant approach for interpreting gender and sexual development, especially in the United States. Any departure from what analysts saw as normal gender roles was treated as a psychological problem. By midcentury, some psychoanalysts were contending that a female orientation among people assigned as male came from too much maternal attention or from life trauma. Analysists and doctors would then try to treat boys who didn’t conform to masculine norms. These theories and therapies guided interventions that persisted for decades, eventually evolving into what became known as “conversion therapy” or reparative therapy—practices now widely discredited and banned in several states.

Clinics serving transgender adults, rather than attempting to “cure” them, began appearing in the U.S. in the mid-to-late 20th century, often operating at the edges of mainstream medicine. Some were affiliated with academic centers or specialized hospitals, offering hormone therapy, psychotherapy, and gender-affirming surgeries under strict protocols. 

These early clinics, which laid the groundwork for a medical understanding of gender identity, were subject to controversy—frequently marginalized, shut down, or later banned outright in several states as part of shifting political climates. Despite the setbacks, their existence provided a foundation for the eventual inclusion of adolescents in care. By the 1990s, a handful of adult-focused transgender clinics began cautiously extending services to youth. At the same time, mounting recognition of the harms caused by conversion therapy catalyzed a broader rethinking of how best to support transgender adolescents.

In the Netherlands, this shift in thinking inspired what would become known as the Dutch model. For carefully selected adolescents experiencing persistent gender dysphoria—a distress that arises when a person’s gender identity does not align with their body or assigned sex—clinicians introduced puberty blockers. These medications paused physical development, offering time and space for identity to emerge without the pressure of irreversible bodily changes. 

This approach emphasized psychological screening, parental involvement, and watchful waiting, encouraging families to support their child without pushing toward or against transition. Although the Dutch model was introduced at a time when little data existed about long-term outcomes, especially for youth, it marked a major turning point: For the first time, there was a measured, non-coercive method for treating gender dysphoria, grounded in psychological well-being and long-term follow-up.

In the decades since the establishment of the Dutch model, research has shown that children who have socially transitioned—that is, who have begun living as their self-affirmed gender—experienced typical emotional and cognitive development, with no increase in psychological distress. These findings helped shift clinical thinking, paving the way for the modern gender-affirmative model of care for gender-dysphoric young people.

The gender-affirmative approach, now widely used across the U.S. and in parts of Europe, centers on the patient’s experience. It emphasizes listening carefully to what children and adolescents say about their identity, supporting families, and creating individualized care plans based on each individual’s specific needs and goals.

In 2007, the first U.S. pediatric gender clinic based on this model opened at UCSF Benioff Children’s Hospital in San Francisco. The Child and Adolescent Gender Center there became a national model for interdisciplinary care.

Like the Dutch protocol, the gender-affirmative model may include puberty blockers, which pause puberty to allow patients and their families more time for exploration and discussion. But blockers are not used automatically. Puberty suppression is offered only after careful psychological and clinical assessment, and only if it aligns with the informed goals of the minor and their family. Hormone therapy can be considered closer to the age of adulthood if gender identity persists. 

Contrary to the intense media focus and frequent political hyperbole, these interventions remain extremely rare. Roughly 300,000 adolescents in the U.S. identify as transgender. Yet according to recent insurance data, only 0.01 to 0.02 percent of U.S. adolescents with private coverage (about 55,000 to 110,000 youth) have received puberty blockers. Children are never given treatment in secret, without the knowledge of their families. 

Another common misconception: Surgical interventions are not a focus of care for transgender minors. In fact, they are rare and typically delayed until adulthood, if pursued at all. One cohort study found that over a four-year period, 2016 to 2020, there were just 3,678 procedures performed on transgender minors. Of these, the majority were breast and chest procedures. 

In contrast, cisgender adolescents regularly receive appearance-altering surgical procedures. In 2022 alone, 23,527 adolescents in the U.S. received cosmetic procedures aimed at their assigned genders, including breast augmentations for girls and breast reductions for both girls and boys. The last of those procedures is often used for cisgender boys who have gynecomastia, a benign overgrowth of breast tissue. (That same year, more than 200,000 additional youth under the age of 19 received more minor cosmetic surgeries, including nose jobs and ear reshaping.)

Such procedures remove healthy tissue to align a teen’s appearance with their self-image. They are irreversible, and yet widely accepted as routine medical care without public outcry. 

This discrepancy raises a key ethical question: Why is affirming care considered acceptable for cisgender youth but not for transgender youth—even when the care for trans youth is often less invasive?The only answer that makes sense is one rooted in the belief that being transgender is, in and of itself, a form of harm. That false belief, in turn, is rooted in the ideological concept that there are “just two sexes.” 

Although classification into two sexes and genders is a common societal norm, it is not a biological reality, nor has it ever been even a social absolute. Just because the majority of people find comfort in binary (or seemingly binary) identities doesn’t negate the reality that a gender spectrum exists both scientifically and culturally. 

Historical records show that gender has never been a fixed or universal construct. Across cultures and centuries, individuals have defied the rigid categories of biological sex and social gender. Some were people whom we would now understand as having differences of sex development (also called intersex), or natural variations in chromosomes, hormones, or anatomy that don’t fit typical definitions of male or female. Others lived in roles outside the binary, taking on culturally recognized third genders or identities distinct from Western norms.

Biology itself resists a strict male-female binary. For instance, children born with 5-alpha-reductase deficiency, which leads to very low levels of the male developmental hormone dihydrotestosterone, are often raised as girls until their testes descend and penis becomes obvious around adolescence. This condition exists around the world and has been culturally accepted in the Dominican Republic, where these children are called Guevedoces.

Then there’s androgen insensitivity syndrome, in which individuals have XY chromosomes (what we typically define as male) but their bodies are unresponsive to androgens, the hormones that trigger male development. As a result, they often develop external anatomy typically associated with females and may not know they have the syndrome until puberty. In daily life, they are often perceived—and may identify—as female.

Even chromosomes, often seen as the bedrock of biological sex, don’t provide a reliable dividing line. People with Klinefelter’s syndrome have an extra X chromosome (XXY), while those with Turner’s syndrome have only one X (X0). Both conditions can affect secondary sex characteristics, fertility, and development in ways that blur conventional expectations of what it means to be biologically male or female.

These variations aren't errors. They are natural examples of human diversity. And they remind us that biology is far more complex than the checkboxes on a birth certificate.

Today’s conversations about gender dysphoria have echoes in how children with differences of sex development were treated in the past. One well-known, tragic example is the case of David Reimer. In the 1960s, after a botched circumcision left him without a functional penis, Reimer’s parents turned to sexologist John Money for guidance. Money believed that gender identity was entirely shaped by environment and upbringing, a theory known as the nurture model. He advised Reimer’s parents to raise David as a girl, while his twin brother remained a boy. 

Reimer was socially transitioned (given a feminine name and clothing) and underwent treatments meant to reinforce this identity. But the approach failed. Despite Money’s efforts, Reimer consistently identified as male and later transitioned back. Both he and his twin brother died by suicide in adulthood. Known as the John/Joan case, this episode profoundly challenged the idea that gender identity can be created or changed through social conditioning alone. It also raised serious ethical questions about imposing identities on children without their input, a cautionary tale that resonates today. 

The moral of the story is that the nurture theory of gender—that one can convert someone’s sense of gender identity—is both wrong and harmful. So are theories that support conversion or reparative therapies. Gender identity and expression are complex and personal. Listening, affirming, and guiding with developmental and psychological support provide the best approach for good outcomes. 

Starting around 2015, pediatric gender-affirming care became hyper politicized in the West. Even valid disagreements or criticisms of care strategies were overshadowed by exaggerated claims, inflammatory stories, and cherry-picked results from studies. The consequences hit quickly, as new legislation began citing politically motivated misinformation both in the U.S. and Europe.  

A prime example is the UK’s Cass Report, a government-commissioned review of gender-affirming care for youth, led by British pediatrician Hilary Cass. The Cass group intended to create a sober document and was in some ways supportive, but it has been twisted to become a tool of the anti-trans movement, widely cited in efforts to restrict care. 

The Cass Report itself is somewhat problematic. Despite its impressive pedigree, it contains serious methodological flaws—including reliance on retrospective case reviews instead of prospective studies, exclusion of affirming research, and disproportionate attention to rare or atypical cases. The report also gives space to outdated ideas, such as the long-discredited nurture theory of gender, which claims gender identity is shaped solely by upbringing.

Because of its cautious tone, the Cass Report has been widely misrepresented as a “nail in the coffin” for gender-affirming care. This distortion has been used by critics to falsely claim scientific consensus against treatment. 

Look at the actual report, though, and you will see that it recommends that puberty blockers be prescribed in a research setting, not banned, and it explicitly affirms that hormone therapy remains appropriate for many patients. The report concludes that gender-affirming care can be necessary and effective. Strikingly, many of its final recommendations echo those of the World Professional Association for Transgender Health (WPATH), the leading international organization setting standards for gender-affirming medical and psychological care—including suggestions to expand gender-affirming education, oversight, and equitable access. 

Meanwhile, other expert bodies have similarly endorsed the value of gender-affirming care. The French Society of Pediatric Endocrinology and Diabetology, convened to analyze the evidence and develop guidelines on the medical management of transgender adolescents, ultimately supported the WPATH and US medical groups’ approach. Germany, Austria, and Switzerland have come to the same conclusions through their own reports. Even a recent report ordered by Utah legislators, following a state ban on gender affirming care, concluded that the care is not harmful, does provide benefits, and that the ban is not justified by the available evidence.

Unfortunately, actual medical evidence has largely been drowned out in the rhetoric-driven cultural battles over trans rights and gender-affirming care. Decades of research shows that puberty blockers can be effective and are highly unlikely to cause harm. These drugs have been used safely for years to pause development so teens have time to work through their identity—not just in cases of gender dysphoria, but also for medical conditions like premature puberty. 

The fundamental aim of gender affirming care is to treat young patients in the gentlest way possible. We know these therapies work, and we know they’re safe. But that is not how the therapies are typically presented in the current public debate, where people claim that doctors are mutilating children too young to make informed decisions, overruling parental wishes, and (in the most extreme ideologies) going against the order of nature.

For doctors and medical ethicists like myself, our challenge is to cut through the misinformation while performing a delicate balancing act for the patient. How do we care for the young person standing in front of us while also considering who they’ll become as an adult? 

To make ethical decisions, we must start with three things: What we know, what we don’t, and what we’re worried about. We know that gender dysphoria can deeply affect mental health. Studies show that simply receiving support improves patient outcomes. Pausing puberty gives adolescents time to think and explore, without locking in physical changes that might later feel wrong. We also know that doing nothing can leave a young person stuck in emotional distress, making it harder for them to thrive.

Helping a child feel mentally well lays the foundation for a healthy, successful adulthood. But this care is never one-size-fits-all. Every young person is different—emotionally, medically, socially. That’s why every treatment must be tailored to the individual. No one can predict the future, but helping a child today also helps the adult they will become tomorrow.

So how do we proceed when we can’t see the future clearly? The answer is shared decision-making. That means the young person, their parents, and their doctors come together to weigh the facts, talk about goals and values, and make the best choice they can, together. As children grow into teens, they should take on more responsibility for their own healthcare decisions. Puberty blockers and hormones are no exception. The process should be thoughtful and respectful, taking into account both the potential benefits and any burdens for that individual child.

In the end, it is our responsibility as doctors to give youth the best possible path to become happy, healthy adults. Contrary to the incendiary political myths, our children are not being shunted into secret clinics and transitioned to other genders. Instead, doctors are working with parents, as a team, to figure out what is best for their kids. That’s it. That’s the whole radical ideology of gender-affirming care! This reality may be obvious to doctors and many parents of trans teens, but it’s not well understood by much of the population. 

Parents, too, want the best possible outcomes for their children, which is why we work closely with them, always. Together, we want to help kids make the right choices—not just for today, but for tomorrow. Adolescents should be involved in decisions over their body with increasing autonomy as they age. Gender-affirming care is not just compassionate care. It is ethical care and best medical practice, aligned with the same guidelines we use in all pediatric medicine.

This story is supported by a grant from the Pulitzer Center.