Transgenderism, Gender Diversity, and the Impact on Children and Education
Transgenderism and gender diversity describe individuals whose gender identity or expression differs from their assigned sex at birth, including transgender (male, female, or nonbinary) and gender-diverse identities that challenge binary norms. Increased visibility of transgender and gender-diverse (TGD) youth has sparked debates about their experiences in schools and healthcare, focusing on affirming identities while addressing mental health and medical intervention concerns.
In May 2025, the U.S. Department of Health and Human Services (DHHS) released a 400-page report, "Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices," per Executive Order 14187, “Protecting Children from Chemical and Surgical Mutilation.” The report challenges the World Professional Association for Transgender Health (WPATH) Standards of Care, arguing that evidence for gender-affirming interventions like puberty blockers and hormone therapy is weak and treatments carry significant risks. The articles and information we include examine these complex issues cited by the Report and implications going forward.
US DHHS Report on Gender Dysphoria
and WPATH Response
DOWNLOADABLE TEXT AT BOTTOM OF ARTICLE
Foreword by Pavement Education Project
The Report on Gender Dysphoria, including medical transition for minors, from the US Department of Health and Human Services was issued on May 1, 2025 (link provided below). It is fairly long (266 pages not including Appendices and Bibliography) and at times technical. But it contains extremely important information for parents of children who experience discomfort or anxiety over their sex and pubertal changes in their bodies, as well as for school board members, policy makers, lawmakers, and all persons of goodwill who are concerned for the well-being of children and adolescents who experience these feelings. School officials and Board members especially need to understand the Report because their actions to socially transition students (allowing use of opposite sex bathrooms and locker rooms, alternate pronouns, playing on sports teams of the opposite sex, GSA clubs, etc.) are not neutral acts that allow kids to explore their gender, but rather active interventions that psychologically condition children and adolescents to proceed onto medical transition (see our own brief review of the research on social transition elsewhere on our website).
The Report comprises a summary of 17 international systematic reviews of the medical and psychiatric literature, including the Cass Review for NHS England (link provided below). These reviews evaluated the quality of evidence for gender transition of children and adolescents (i.e., how certain (or not) are the benefits that have been claimed). The reviews were performed by specialists with expertise in research methodologies and quality of evidence. The reviews found that the evidence supporting medical gender transition of minors was remarkably weak because of numerous methodological flaws such as lack of appropriate control or comparison groups, confounding variables, short term follow up, attrition, loss to follow up, small sample size, and reliance on voluntary patient self-assessment instead of clinical observations of mental health. The Report critiques in detail several seminal research studies, including the two original “Dutch Protocol” papers and two 2023 publications from different research groups that have been frequently cited to justify gender transition of minors. The Report points out how both the patients and the data were selected in these papers to favor making the claim for positive benefits. The Report also points out what are not adequately captured by the reviews, namely the possible harms caused by the treatments themselves, because these have generally not been the focus of the research publications.
Beyond the evidence reviews, the Report details serious irregularities in the process of developing the World Professional Association for Transgender Health (WPATH) Standards of Care, version 8 (SOC-8, link provided below) that have been uncovered through the discovery process and depositions in court cases over certain state laws banning medical treatments to change the gender of minors (at the time the present Foreword was being written, the US Supreme Court upheld Tennessee’s law in United States vs Skrmetti). Despite claims in SOC-8 that its recommendations were evidence-based, it was uncovered that WPATH leadership did not allow publication of a number of evidence reviews that it had contracted a team at Johns Hopkins University to conduct after it became apparent that these reviews did not find strong evidence to justify certain treatments. Further, the strength of the recommendations were increased under pressure from Rachel Levine, Assistant Secretary of Health in the Biden Administration DHHS, without the consensus of the 119 co-authors of SOC-8 in contradiction to statements in SOC-8 itself that the formal process known as DELPHI was used to achieve consensus. Similarly, all the minimum age recommendations except for one that were agreed upon by consensus of the co-authors were deleted even after initial publication under pressure from certain officials of the American Academy of Pediatrics (AAP). The evidence presented suggests that these modifications were made to SOC-8 without going through the DELPHI process and not based on the medical evidence, but in order to shore up the legal position against state laws limiting medical gender treatments for minors. These revelations about the development of SOC-8 call into question the credibility of WPATH as an objective medical association grounded in science and ethics.
Although the SOC-8 claims of “medically necessary” and even “life saving” still need to be maintained to get insurance claim reimbursements as well as support the position in court and legislative battles, the rationale for medical gender transition of minors recently has been shifting toward patient civil rights and autonomy. The Report points out how treatment for minors has shifted from the original “Dutch Protocol” requiring careful assessment of how longstanding the minor patient’s dysphoria has been, to now the “Gender Affirming” model wherein as soon as a patient declares that he or she is the opposite gender, that must be affirmed (accepted) and transition commenced shortly thereafter. (It is noted however that even sticking with the Dutch approach, there is no way to determine which patients will indeed persist in a life-long dysphoria.) At Pavement Education Project, our opinion of this autonomy argument is not only that it obliterates patient safeguards, but that the principle would allow consent by minors for all sorts of other things.
Interestingly, the Dutch Protocol also required the approval and support of parents for the transition, whereas now in some states, such as California, and in many locales, children may be taken out of homes if parents do not go along with the gender transition. (Many school districts, including even a few in NC, will not inform parents of their child’s social transition unless the child permits “on a case-by-case basis.”) The Dutch Protocol study made the representation that the patients in that study did not have psychiatric co-morbidities. But the international systematic reviews found that the patient demographic now presenting at gender clinics includes a majority suffering other psychiatric co-morbidities. A significant minority have suffered sexual abuse. A large percentage is also neuro-diverse (autistic and/or having ADHD). The great majority are attracted to the same sex. The patient demographic has also shifted in recent years from mainly pre-pubescent boys to adolescent girls instead, tracking the rise in mental health disorders among adolescent girls. Yet SOC-8 does not even consider that gender dysphoria and the desire for transition could be an inter-related, mal-adaptive coping mechanism for other co-morbidities and adverse childhood experiences. The position in SOC-8 is that co-morbidities may be treated concurrently with medical gender transition treatments, but not before or in place of the gender transition.
The day after the Report was published, WPATH and USPATH issued a joint response (link provided below) blasting the Report, as did the AAP. They repeat assertions that gender affirming care is based on thorough evaluation of evidence and rigorous research. But, the quality of evidence is precisely what is challenged in the Report and the 17 comprehensive international reviews of the medical literature. The reviews found that many studies were not rigorous, but had various methodological flaws. In our opinion, for WPATH-USPATH simply to make this assertion is really no response at all because no specific analysis or reasons are offered to show how the international reviews got it wrong in concluding that the evidence is remarkably weak. The chapter on adolescents in the WPATH SOC-8 even says that “A key challenge in adolescent transgender care is quality of evidence evaluating the effectiveness of medically necessary gender-affirming medical and surgical treatments.” So, which is it? How can it be claimed as medically necessary if the evidence doesn’t strongly support it? The present WPATH-USPATH response does refer to critical findings in recent studies, but gives no details or citations. Isn’t this an admission that gender affirming care for minors has been rolled out for many years without solid evidence to justify it, at least until recently (if at all)? In fact the Report does address studies that have come out since the international reviews within the last year. The Report notes that these studies suffer some of the same methodological flaws as the earlier studies included in the systematic reviews.
The WPATH-USPATH response states that clinical practice guidelines (CPGs), including SOC-8, “are developed [sic] thorough evaluation of evidence, clinical expertise, patient values and preferences, and cultural and contextual considerations.” This begs the question: Are the CPGs based on evidence, or more on all those other things that are nebulous and ill-defined? What good is clinical experience if the evidence has not been found to justify the risk/benefit of the treatments? Again, how can they talk about thorough evaluation of evidence when SOC-8 said the quality of evidence was a key challenge, and further said that systematic reviews were not possible because of this? Moreover, as mentioned above, the record in the court cases challenging state laws restricting such treatments for minors shows that the SOC-8 guidelines were significantly altered to bolster legal arguments, not to follow the medical evidence.
It is telling that the WPATH-USPATH response uses the term “Gender-Affirming Care” as opposed to pediatric medical gender treatments. This means that whatever gender identity a child declares must be affirmed and not questioned. This may be why “patient values and preferences” are included in the list of things that the CPGs are based upon. As a consequence, the WPATH-USPATH support for a “comprehensive, multidisciplinary assessment” is limited to co-occurring mental health issues and does not include an assessment of how long-standing or stable the professed identity has been (unlike the original Dutch protocol), or whether it is being sought as an escape from other problems.
The joint WPATH-USPATH response also keeps repeating the claim that there is medical consensus for medical gender transition of minors. No, there is not!!! As a result of the international reviews, many countries, including the UK and the Nordic countries, have greatly curtailed the medical transition of minors and instead emphasize psychotherapy as the first line of treatment. Some of the key doctors who pioneered gender medicine have turned against medical transition of minors. A significant number of AAP’s members dissent from that organization’s position, too. WPATH-USPATH pontificates in their response that healthcare decisions should not be in the hands of politicians, yet the court record discussed above reveals that SOC-8 was substantially altered under pressure from a Biden Administration official. We find it odd that WPATH-USPATH would close their response with a statement that transgender healthcare policies should be guided by clinical evidence, not ideology.
To make well-informed decisions on a matter of such serious consequence, all concerned parties need to put in the time to thoughtfully study the 2025 DHHS Report and also the Cass Review. The WPATH SOC-8 should also be read and studied in comparison. Readers will then be able to form their own opinion whether the WPATH-USPATH response has substance. Links are provided below.
US DHHS Gender Dysphoria report:
https://opa.hhs.gov/gender-dysphoria-report
Cass Review for NHS England:
WPATH Standard of Care, version 8:
https://www.tandfonline.com/doi/pdf/10.1080/26895269.2022.2100644
WPATH-USPATH response to DHHS Gender Dysphoria report:
https://wpath.org/wp-content/uploads/2025/05/WPATH-USPATH-Response-to-HHS-Report-02May2025-1.pdf
This document is intended to be used complete and unaltered. Any edits or modifications should be approved with the Pavement Education Project beforehand to maintain the intended message and integrity of the content.
Social Gender Transitioning by Schools
This document is intended to be used complete and unaltered. Any edits or modifications should be approved with the Pavement Education Project beforehand to maintain the intended message and integrity of the content.
DOWNLOADABLE TEXT AT BOTTOM OF ARTICLE
Social Gender Transitioning by Schools
The recent inclusion of gender identity into the anti-discrimination policies of the Wake County Public School System, among other districts, will mean that the social transition of trans-identifying children and adolescents will be practiced by public schools. There are two sets of concerns arising from this action: (1.) What are the outcomes for those who undergo gender transition beginning with social transition, and (2) what will be the impact on faculty, staff, and other students who will be required to assent to social transition in their schools. The present article will deal with just the first concern. The authors wish to make clear that we do not wish to cause distress or any harm to those experiencing real difficulties over their gender. Quite the contrary!!! We wish people to be well-informed so that policies and treatments most beneficial for those having very real feelings of distress may be found by following the science.
The first step in gender treatment for minors is often social transition in school. A review of gender care for children and adolescents was commissioned by NHS England and headed by renowned pediatrician Dr Hilary Cass. The Review took 4 years and the final report1 was published in early 2024. The Review concluded that social transition is an active intervention even though not conducted in a clinic.1 The Review came to this conclusion because evidence suggests that the percentage of students who persist in Gender Dysphoria is increased by social transition,2,3 and most of these proceed onto a medicalized pathway of puberty blockers and hormones.3 For example, one study cited in the Review found that 97.5% of those socially transitioned persisted (94% as trans and 3.5% as non-binary) after 5.4 years, and a total of 71.6 % had proceeded onto the medical pathway, including those already on puberty blockers at the start, by the time the study concluded.3 The percentage who ultimately go on the medical pathway will undoubtedly be much higher because many had not yet reached the age minimum recommended for medical transition by the time the study concluded.3 This is in sharp contrast to many studies that have shown that the overwhelming number of children who have felt Gender Dysphoria outgrow those feelings as they go through puberty if left alone without any intervention.4,5,6,7 Even the clinical guidelines from the pro-trans Endocrine Society acknowledges that social transition is associated with increased persistence, whereas only a minority of pre-pubertal children would otherwise persist.8 There is no objective way to test which patients will persist and which will not,8,9 Factors associated with persistence or desistance have been identified.4,6 Some argue that the high persistence rates were because those who had the strongest Gender Dysphoria were most likely to socially transition.1,4 But this is speculation, because the persistence with social transition has not been compared within the same study with controls without social transition appropriately matched based on some measure of intensity of Gender Dysphoria. The complete switch in persistence rates between the separate studies with and without social transition, coupled with the dramatically increased number of patients who have socially transitioned in recent years,4 makes it difficult to place much reliance on this hypothesis. Moreover, this and other factors associated with persistence have been considered of low clinical utility because of the highly variable nature of individual patient presentations.6
Now, it should be noted that since about 2014, the patient cohort seeking gender treatment has risen exponentially and has also dramatically shifted from almost all pre-pubescent boys to now about 75% or more girls who have already begun puberty and most of whom have psychiatric co-morbidities and/or neurodiversity.1,10 For now, there is no data to suggest that this new demographic would not also get over Gender Dysphoria without social transition, particularly if their other problems were addressed first. The Cass Review notes that we do not know how the new patient cohort would have resolved their Gender Dysphoria because alternate therapies aimed at reducing distress or no intervention at all have not been tried with this cohort.1 In many settings now, therapy to help young people come to accept their sex and body is banned or at least condemned as a form of conversion therapy.1,11,12
Some studies have reported short term improvements in mental health and/or social functioning of students who have socially transitioned.13,14 However, the Cass Review found that no firm conclusion could be drawn from these studies because they were of low quality.1 The quality ratings were provided to the Review by a group at the University of York who are expert at rating the quality of scientific and medical studies.1 Other studies,4,15,16,17 including two rated as moderate quality,4,15 reported no improvement in mental health from social transition. In the latter paper (recently published and not rated in the Cass Review), the authors, one of whom was a top manager of the Tavistock Gender clinic in England before it was shut down, caution that their results should not be taken as proof that there is no benefit to social transition.17 But yet no clear benefit has been demonstrated. (It is interesting to note that the time from when this paper was initially submitted to the journal until its acceptance was nearly four years.17 Anyone experienced in the peer review process for scientific or medical journals would suspect that this length of time before acceptance indicates that there was serious contention between the reviewers, authors, and editor over some aspects of the study, and/or its conclusions, and/or citations of competing views.) Some leading figures in the field of psychiatry who are not opposed to transgender identities and who have treated many patients, have raised very strong ethical and medical opposition to the gender-affirming care model for minors.18, 19, 20 Many rank-and-file clinicians, who went to work at the now shuttered Tavistock clinic because they wanted to help transgender youth, reported grave concerns that they were actually harming their young patients, many of whom presented at the clinic already fully socially transitioned from school with their hearts set on getting puberty blockers and hormones, when clinicians referred those young patients for the said medical treatments.21
The Cass Review did not recommend an outright prohibition of social transition in schools but recommended that it be done with extreme caution only under supervision of a clinician, and only after addressing other mental health issues, and only with involvement of parents.1 Note that the State of California has definitively taken the opposite approach on this last point after Governor Newsom signed into law AB 1955 which prohibits local school boards from requiring that parents be informed of their child changing their gender identity in school.22 Thus in California, everyone including administrators, teachers, and other students will know a child is socially transitioning, but not the child’s parents!!! This has already been defacto policy in many locales even though legislative approval has not been given and people have not voted for it.
In summary, the preponderance of evidence shows that the strong majority of children will outgrow Gender Dysphoria as they go through puberty if left alone, or perhaps were to receive alternative talk therapy and treatment for their mental health problems. But if they are socially transitioned, there is a very high probability that they will persist and go onto life-altering and life-long medical treatments that involve iatrogenic harms and side effects without ever having felt or experienced their natal gender in maturity after completing puberty. Moreover, there is little to no evidence that social transition improves psychological functioning or mental health. It is therefore hard to see how social transition could be medically indicated. If public schools truly want to protect trans kids, they should not implement social transition.
References
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https://cass.independent-review.uk/home/publications/final-report/
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Zucker, K. J. Debate: Different Strokes for Different Folks. Child & Adolescent Mental Health 2020, 25, 36 at 36–37. Available at https://doi: 10.1111/camh.12330
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Olson, K. R. et al. Gender Identity 5 Years After Social Transition. Pediatrics 2020, 150, 1-7. Available at https://doi.org/10.1542/peds.2021-056082
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Steensma, T., et al. Factors Associated with Desistence and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-Up Study. J. Am. Acad. of Child & Adolescent Psychiatry 2013, 52, 582-90. Available at https://doi.org/10.1016/j.jaac.2013.03.016
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Steensma, T. D., Kreukels, B.P., de Vries, A.L, Cohen-Kettenis, P.T. Gender Identity Development in Adolescents. Hormones and Behavoir 2013, 64, 288-297.
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Ristori, J. and & Steensma, T. Gender Dysphoria in Childhood. Int’l Rev. Psychiatry 2016 28, 13–20.
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Singh, D., Bradley, S. J., and Zucker, K. J. A Follow-Up Study of Boys With Gender Identity Disorder, Frontiers in Psychiatry 2021, 12, 1-18. Available at https://doi: 10.3389/fpsyt.2021.632784
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Hembree, W. C., et al., Endocrine Treatment of GenderDysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J. Clinical Endocrinology & Metabolism 2017, 102, 3869-3903. Available at https://doi.org/10.1210/jc.2017-01658
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Laidlaw, M. K., et al., Letter to the Editor: Endocrine Treatment of Gender-Dsyphoria/GenderIncongruent Persons. J. Clinical Endocrinology & Metabolism 2019 104, 686.
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Littman, L. Rapid-Onset Gender Dysphoria in Adolescents and Young Adults. Plos One 2018, 13, 1-44. Available at https://doi.org/10.1371/journal.pone.0202330
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Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., . . . Zucker, K. Standards of care for the health of transsexual, transgender and gender non-conforming people, version 7. International Journal of Transgenderism, 13, 165–232.
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Adelson, S.L. Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 2012, 51, 957–974.
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Durwood, L., McLaughlin, K. A., & Olson, K. R. Mental health and self-worth in socially transitioned transgender youth. Journal of the American Academy of Child & Adolescent Psychiatry, 2017, 56, 116–123.
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Olson, K. R., Durwood, L., DeMeules, M., & McLaughlin, K. A. Mental health of transgender children who are supported in their identities. Pediatrics, 2016, 137(3). Available at https://doi.org/10.1542/peds.2015-3223
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Sievert, E. D. C., et al., Not Social Transition Status, but Peer Relations and Family Functioning Predict Psychological Functioning in a German Clinical Sample of Children with Gender Dysphoria. Clinical Child Psych, & Psychiatry 2021, 26, 79-95. Available at https://doi.org/10.1177/1359104520964530
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Wong, W. I., van der Miesen, A. I. R., Li, T. G. F., MacMullin, L. N., & VanderLaan, D. P. Childhood social gender transition and psychosocial well-being: A comparison to cisgender gender-variant children. Clinical Practice in Pediatric Psychology, 2019, 7, 241–251. Available at https://doi.org/10.1037/cpp0000295
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Morandini, J.S., Kelly, A., de Graaf, N.M. et al. Is Social Gender Transition Associated with Mental Health Status in Children and Adolescents with Gender Dysphoria? Arch Sex Behav 2023, 52, 1045–1060. Available at https://doi.org/10.1007/s10508-023-02588-5
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Levine, S. B. Ethical Concerns About Emerging Treatment Paradigms for Gender Dysphoria. J. Sex & Marital Ther. 2018, 44, 29. Availailable at https://doi.org/10.1080/0092623X.2017.1309482
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Riittakertu Kaltiala (2023) The Free Press. Available at https://www.thefp.com/p/gender-affirming-care-dangerous-finland-doctor
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Ruuska, S. M., Tuisku, K., Holttinen, T., & Kaltiala, R. (2024). All-cause and suicide mortalities among adolescents and young adults who contacted specialised gender identity services in Finland in 1996-2019: a register study. Available at BMJ Mental Health, 2024, 27, 1-6. Available at https://doi. org/10.1136/bmjment-2023-300940
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Hannah Barnes, “Time to Think. The Inside Story of the Collapse of the Tavistock Gender Service for Children.” Swift Press, 2023.
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Text available at https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202320240AB1955
This document is intended to be used complete and unaltered. Any edits or modifications should be approved with the Pavement Education Project beforehand to maintain the intended message and integrity of the content.
