INSTITUTIONAL CAPTURE
The assertion that “gender-affirming care” (GAC: puberty blockers/opposite-sex hormones/elective cosmetic surgeries) is based on robust evidence is false. If we pull back the curtain even slightly, we see unsound studies that fail every test for rigor, and political agendas taking precedence over science. Our once-trusted medical institutions have allowed activism to infiltrate and eventually control their practices, undermining both their ethics and credibility. The public trust has been betrayed and countless patients have suffered.
​As of this writing, 27 states have passed legislation to limit or ban GAC. In June 2025, the U.S. Supreme Court ruled in United States v Skrmetti that such legislation is constitutional. Despite the restrictions now in place, vulnerable young people, particularly in blue states, are still at risk because almost every medical organization in the U.S. continues to promote interventions that are not evidence-based. They are following guidance from the discredited World Professional Association for Transgender Health (WPATH). For their most recent “guidelines” (2022), WPATH suppressed the findings from their own evidence review when it failed to support their recommendations. The most progressive countries in Europe—those that we lefties love to trot out as exemplars, including Finland, Sweden, and Denmark—have limited these interventions. Why? No evidence was found to support them.
In April 2024, the most comprehensive review of gender medicine conducted to date, the Cass Review (National Health Service, England), included a systematic evidence review of guideline quality based on an analysis of 19 international guidelines (including five from the U.S.). Of these, only two (from Sweden and Finland, countries that have banned pediatric gender medicine) “scored higher than 50% for rigor of development [the adherence to the scientific method to ensure robust and unbiased experimental design, methodology, analysis, interpretation and reporting of results] due to their evidence-based approach and transparent reporting. They were also the only guidelines which included a formal ethics review and they both scored highly on stakeholder involvement.”
The Cass Review also exposed the shady practice of “circular referencing“ within and between medical organizations, which creates the appearance of consensus. Also known as “citation laundering,” the practice involves multiple organizations referencing each other’s research as sources despite low-quality or non-existent underlying evidence. The two most influential guidelines in the U.S., those from WPATH and the Endocrine Society (ES), referenced each other’s poor evidence, and other major medical associations then followed suit. All these organizations are actively deceiving and betraying public trust by portraying their policies as “evidence-based.”
​​In November 2025, the U.S. Department of Health and Human Services (HHS) published Review of Evidence and Best Practices in the Treatment for Pediatric Gender Dysphoria, an “umbrella review” that analyzed findings from 17 prior systematic reviews. As with all other such efforts, the HHS scientists found no good evidence that GAC benefits youth. Too many Democrats—and most U.S. medical groups, as detailed below—will ignore this because it came from the Trump Administration. Read coverage of initial May 2025 release of the the HHS Review from The Economist.
The institutions that are sacrificing their credibility are:
THE AMERICAN MEDICAL ASSOCIATION (AMA)
The AMA's stated mission is to "promote the science and art of medicine and the betterment of public health." Ironically, the AMA bases its official statement of GAC for children on cherry-picked, inapplicable, and/or outdated sources. For example, to support the claim that GAC for children improves mental health, they cite an article in the Journal of Sexual Medicine that is based on a study in which the participants were 18 years or older. The AMA’s claim that gender medicine reduces suicide attempts, depression, and anxiety is based on a 2010 systematic review of adult patients after the administration of opposite-sex hormones and sex-trait modification surgeries, and a 2005 journal article on “sex reassignment” of adolescents and adults that cites no evidence to support the claim.
THE ENDOCRINE SOCIETY (ES)
The ES’s stated mission is to “improve patient care and shape effective policy.” Their current gender-specific policies (2017) reference other national and regional guidelines to claim that there is medical consensus, but their analysis is based on their own original recommendations rather than new research. The circularity of this approach is highlighted in the Cass Review (see page 130). The ES guidelines rate the quality of evidence supporting its gender-specific recommendations as “low” or “very low.” Given that the ES is a national leader providing clinical practice guidelines and professional development, their promotion of experimental interventions for children based on what they themselves acknowledge is low-quality evidence is shocking and unprincipled. The Cass Review gave the ES’s latest guidelines a 4 out of 7, with one appraiser recommending the guidelines not be followed at all.
THE AMERICAN ACADEMY OF PEDIATRICS (AAP)
The very powerful AAP identifies itself as “an organization of 67,000 pediatricians committed to the optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults.” The organization has taken an activist role against GAC bans (and in favor of including boys in girls sports). Oddly, the AAP entrusted most of their policies on GAC to one man: Jason Rafferty. A disclaimer in their guidelines document says “Dr. Rafferty conceptualized the statement, drafted the initial manuscript, reviewed and revised the manuscript, approved the final manuscript as submitted, and agrees to be accountable for all aspects of the work.” In other words, Rafferty was empowered to submit his own work to himself for approval and then (drum roll please), he approved it.
The efficacy of the AAP guidelines has been assessed multiple times and found wanting:
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From 4th Wave Now (2019): “Canadian psychologist and sexologist James Cantor fact-checked the studies cited in the AAP’s policy statement.[49] He found the AAP statement failed to reference outcomes from 11 studies that followed gender-dysphoric (GD) children as they matured. Every one of these studies “found the same thing: Over puberty, the majority of GD children ceased to want to transition.”[50] An affirmation-only approach makes no sense when research shows most children grow out of their gender dysphoria. Cantor concluded, “Not only did AAP fail to provide compelling evidence . . . AAP’s recommendations are despite the existing evidence.”[52]
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All three appraisers for the Cass Review (2024) rated the AAP guidelines as not recommended, with scores of 12 out of 100 for rigor and 6 out of 100 for applicability (whether or not the study can be applied to the specific clinical setting and individual patient)—the lowest applicability score of any guideline evaluated. Rafferty misrepresents the studies he cites, including as evidence studies that looked at sexual orientation, not “gender identity,” and studies that recommended exhausting all other avenues of care before medicalizing.
Dissenters within AAP have tried repeatedly to petition the organization to conduct their own systematic review (learn more about this sad saga from Jenny Poyer Ackerman, a member of DIAG’s Board of Directors). In 2023, AAP grudgingly agreed to do so (providing no timeline) while at the same time reaffirming their 2018 policy statement and consigning thousands of children to infertility and their parents to despair.
The AAP continues to double down, issuing a statement characterizing 2025’s HHS Review as a misrepresentation of the evidence (without providing evidence) and trying to link it to the Trump Administration's stance on childhood immunizations. By dismissing the HHS Review (saying it “relies on a narrow set of data and perspectives”), the AAP is ignoring its own published evaluation of types of medical evidence which places systematic reviews at the top of the hierarchy. Troublingly, the AAP statement was also signed by the American Academy of Family Physicians, American College of Obstetricians and Gynecologists, American College of Physicians, American Osteopathic Association and American Psychiatric Association.
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AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY (AACAP)
The AACAP’s mission is to “promote the healthy development of children, adolescents, and families through advocacy, education, and research, and to meet the professional needs of child and adolescent psychiatrists throughout their careers.” In 2019 they released the "AACAP Statement Responding to Efforts to ban Evidence-Based Care for Transgender and Gender Diverse Youth" which claims to support evidence-based care. Two of the three appraisers for the Cass Review rated the AACAP guidelines as not recommended with a score of 3 out of 7, a lackluster 44 out of 100 for rigor and an abysmal 7 out of 100 for applicability.
AMERICAN PSYCHIATRIC ASSOCIATION (APA)
The APA “is to be the premier psychiatric organization that advances mental health as part of general health and well-being.” (We’re waiting.) APA publishes the influential Diagnostic and Statistical Manual of Mental Disorders (DSM) which in the fifth edition (DSM5) set out the criteria for diagnosing gender dysphoria (based on regressive sex stereotypes and mostly useful to gender clinicians for insurance reimbursement billing codes). APA supports GAC, going as far as recommending whatever medical interventions the discredited World Association for Transgender Health (WPATH) likes. They state: “No mental health evaluation is necessary to receive medical treatment.” As is common, they group gender non-conforming people (tomboys, for example) with those who have adopted a “trans” identity. (Note: The APA was not analyzed by the Cass Review.)
SOCIETY FOR ADOLESCENT HEALTH AND MEDICINE (SAHM)
SAHM is a nonprofit professional society “committed to the promotion of health, well-being and equity for all adolescents and young adults by supporting adolescent health and medicine professionals through the advancement of clinical practice, care delivery, research, advocacy, and professional development.” They support “protecting access to gender-affirming clinical care for transgender and nonbinary adolescents and young adults.” Their guidelines appear to be more concerned about protecting practitioners than protecting adolescents. All three appraisers for the Cass Review rated the SAHM guidelines as not recommended (they received two scores of 1 out of 7 and one score of 2 out of 7) and scored a miserable 17 out of 100 for rigor and 7 out of 100 for applicability.
AMERICAN PSYCHOLOGICAL ASSOCIATION (APA)
APA’s mission is “to promote the advancement, communication, and application of psychological science and knowledge to benefit society and improve lives.“ Their most recent guidelines were published in 2015 (revealing a worrying lack of curiosity about the changing demographics and increasing numbers of youth identifying as transgender since that year). All three appraisers for the Cass Review ranked APA’s gender guidelines as not recommended, further ranking them 24 out of 100 for rigor and 18 out of 100 for applicability. The APA continues to issue policy statements on the need for GAC, ignoring the Cass Review and criticizing any opposition as motivated by bigotry (as seen in their response to the initial publication of the HHS Review in May 2025).
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The above organizations are very powerful, and have circled their wagons (and their referencing!), reinforcing the misconception that GAC is based on solid evidence. Their misinformation has leaked outward and led other institutions to fall in line. Rather than investigate whether what they were being fed was accurate, the following organizations appear to have swallowed it whole and regurgitated it:
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(WPATH/USPATH is left off this list, as they have never been credible and thus, we have generously given them their very own page.)
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The American Society of Plastic Surgeons (ASPS) was the first major U.S. medical association to break ranks. On August 12, 2024, the ASPS released a statement saying "ASPS has not endorsed any organization's practice recommendations for the treatment of adolescents with gender dysphoria. ASPS currently understands that there is considerable uncertainty as to the long-term efficacy for the use of chest and genital surgical interventions for the treatment of adolescents with gender dysphoria, and the existing evidence base is viewed as low quality/low certainty." DIAG applauds ASPS and hopes their fellow practitioners follow suit!