The first malpractice verdict against a provider of ‘gender-affirming care’ for a minor arrived in 2026. Fox Varian, a brave young woman who underwent a double mastectomy at sixteen, sued the psychologist and plastic surgeon responsible. A jury awarded her $2 million—the first verdict of its kind.
The verdict was a watershed moment. For years, activists and compliant medical organizations insisted gender-affirming interventions were safe, reversible, and lifesaving. That consensus is cracking. Ordinary Americans serving as jurors recognized that removing healthy breasts from a minor is not standard care when proper safeguards are ignored, and they held providers accountable accordingly.
Fox’s story is not unusual among detransitioners: rapid affirmation, minimal mental health screening, no serious exploration of underlying trauma, and little honest discussion of permanent consequences. At sixteen, amid adolescent distress, she identified as male. Doctors proceeded with irreversible surgery. Today, she lives with permanent disfigurement and the physical and emotional scars of a decision rushed through ideology rather than evidence-based prudence.
Yet Fox’s win, while historic, highlights a deeper tragedy. Hundreds, perhaps thousands, of young people have been steered down the same path. She is the first to win. How has the gender industry been able to dodge scrutiny for so long? European countries have already pulled back, citing weak evidence and significant risks. America, despite growing state protections and whistleblowers within medicine, has not yet followed suit.
Why?
The Guild
The gender industry runs an elaborate game of diffused responsibility. Pharmaceutical companies profit from the off-label use of their drugs while disclaiming any role in how clinicians prescribe them. Clinicians protest that they’re only following established guidelines and can’t be held responsible for the harm those guidelines produce. This not only makes it difficult to find someone to blame for gender medical malpractice but also leads to widespread fraud, in both the moral and legal sense of the term.
The central institution in this story is the World Professional Association for Transgender Health (WPATH), which publishes the Standards of Care that American clinicians follow. WPATH presents itself as a reliable, evidence-based medical body. But as the Department of Health and Human Services’ recent review of pediatric medical transition points out, “unlike most professional medical associations, WPATH does not require its members to be medical professionals. Full professional membership with voting privileges is also available to professionals in such fields as law, family studies, anthropology, and other areas.”
The practical result is that non-medical considerations have significantly influenced its published standards. The most recent version—Standards of Care, Version 8, published in 2022—is a case study in how that influence operates.
When the Biden administration reviewed a draft of SOC-8, it warned WPATH that including minimum age recommendations for gender transitions would invite political scrutiny and unwelcome consequences. Against the judgment of some WPATH members, the age recommendations were downgraded from requirements to suggestions and then removed from the final document entirely.
Internal communications from the drafting process reveal the extent to which political rather than clinical aims drove the document. One contributor urged that SOC-8 should “land in such a way as to have serious effect in the law and policy settings … even if the wording isn’t quite correct for people who have the background you and I have.” Members insisted on describing sex-change procedures as “medically necessary”—not because that description reflected clinical reality, but because the term would compel insurance coverage and serve as “a tool for our attorneys to use in defending access to care.” Another contributor suggested avoiding systematic evidence reviews, since “social justice lawyers” had advised that finding insufficient evidence for their recommendations might put them “in an untenable position in terms of affecting policy or winning lawsuits.”
When WPATH did commission systematic evidence reviews from Johns Hopkins University’s Evidence-Based Practice Center, the researchers found “little to no evidence” to justify many of WPATH’s claims. WPATH excluded those reviews from the Standards and prevented Johns Hopkins from publishing them elsewhere.
This lack of evidence should draw regulatory attention. In 2020, the Federal Trade Commission warned that it is unlawful to advertise that a product can treat or cure a condition without “competent and reliable scientific evidence, including, when appropriate, well-controlled human clinical studies.” The warning was issued in the context of COVID treatments. WPATH’s practice of making claims without requiring supporting evidence fits the same standard—and should be held to it.
The Standards
The standards that emerged from this process are notably permissive regarding patient safety. On the question of mental illness and consent, they are striking. The well-being of patients is easily set aside when it threatens to interfere with pharmaceutical or surgical transition.
Despite the lack of evidence, practitioners insist that nearly any patient willing to undergo these procedures should receive them—even those previously diagnosed with serious psychiatric conditions. When faced with such a patient, all providers are required to do, according to SOC-8, is attempt to distinguish previously diagnosed illnesses from gender dysphoria. However, the standards are not only silent on how to do so but also deny that psychotherapy should be a prerequisite for medical intervention and state that psychosis or cognitive impairment “does not necessarily equate to an inability to give consent”—a position contrary to established medical ethics.
Most notably, SOC-8 states that “[l]imits to capacity to consent to treatments should not prevent individuals from receiving appropriate gender-affirming medical and/or surgical treatments.” In such cases, providers are instructed to use simple language and diagrams. That, the standards suggest, is an adequate substitute for the ability to consent. Thus, even if WPATH concedes that psychosis or cognitive impairment compromises one’s ability to consent, the SOC-8 standards make clear that this doesn’t matter.
The one exception is patients who show “gender incongruence” only during an “acute psychotic episode.” In those cases alone, the SOC-8 standards advise against recommending medical transition. The guidelines make clear that little should stand in the way of beginning treatment—and that this applies to the mentally ill as much as anyone else.
Prominent doctors within the field have described the practical application of these guidelines in extreme terms, as noted in The WPATH Files, a report from the group Environmental Progress. The lead author of SOC-8’s mental health chapter has cited, apparently approvingly, case studies in which patients claiming as many as eighty-five other personalities were given these procedures. Another case study described an alcoholic, bipolar patient with seven alternate personalities who was nevertheless permitted to undergo genital nullification surgery—an amputation of the genitals to create a smooth, sexless appearance.
The standard for ceasing treatment due to deteriorations in mental health is set correspondingly high. SOC-8 explicitly counsels against stopping hormone treatment even when patients are admitted to an inpatient psychiatric unit, unless the patient also has an acute, life-threatening condition such as “venous thromboembolism”—blood clots that are typically associated with the elderly and those in heart failure, but also a well-known side effect of cross-sex hormones in the young.
Because even major psychiatric disorders are seen as an impediment only in “rare” cases, WPATH protocols do not absolutely require psychological evaluation for patients, including minors. Parts of the guidelines pay lip service to the desirability of a “comprehensive biopsychosocial assessment” for adolescents starting the transition process but note that recommendations are meant to be “flexible” and that “individual health care professionals and programs, in consultation with the [patient], may modify them” as they see fit.
The original protocols for psychological assessment of transgender-identifying youth—approvingly cited by WPATH in SOC-8 as best supported practice—call for an extensive, months-long process.However, actual adherence to this protocol in the US is vanishingly rare. In 2022, Reuters interviewed staff at eighteen clinics and found that none were following anything resembling what those protocols recommend. Instead, clinics were following WPATH’s own looser guidelines. Still, many professionals argue that even WPATH’s permissive guidelines go too far. Although SOC-8 recommends psychological assessment and “several years” of gender incongruence before prescribing hormones to adolescents, several practitioners have denounced these standards in emphatic terms.
At one prominent pediatric gender clinic, the time devoted to patient assessment fell by roughly 90% between 2013 and 2021, down to approximately 2 hours—a development the clinic’s founder described as “shocking.” In one detransitioner’s account, a doctor diagnosed her with gender dysphoria within minutes and ordered a puberty-blocker implant the same day. Planned Parenthood, one of the nation’s leading providers of hormones for transgender-identifying young adults, appears to generally prescribe them on the first visit, with the process taking roughly half an hour. One psychiatrist at Fenway Health in Boston described SOC-8’s assessment recommendation as “unnecessary gatekeeping and also stigmatizing and pathologizing and a waste of resources.” Another psychologist called the suggestion of “several years” of incongruence before prescribing hormones to adolescents “harmful and destructive and abusive and unethical and immoral.”
Psychiatry may have once been foundational to establishing transgender medicine as legitimate. Now that transgender medicine is big business, it has become optional.
What They Knew
Consistent with the industry’s widespread opposition to anything that might counsel against treatment, practitioners often downplay or omit discussion of potential side effects and risks. One potential side effect of testosterone therapy for women is atrophy of the entire reproductive tract. As The Free Press reported: “Planned Parenthood’s materials for clinicians state atrophy can begin within just 3–6 months of exposure. But on the brief patient consent form […] this was referred to only as ‘genital dryness.’” When a former employee raised concerns about this characterization, she was told that informing patients of lesser-known side effects “would scare them.”
Side effects such as lethal blood clots are downplayed or misconstrued to encourage patients to go through with medical transition. A Planned Parenthood medical director interviewed by The Free Press defended the practice, saying it would be wrong to point patients toward risks that might materialize “10 or 20 years down the road when they’re having lifesaving care right now.” Clinicians are still knowingly misrepresenting adverse side effects. If that isn’t fraud, it is hard to see what is.
In the case of minors, it is unclear how they can meaningfully understand even those risks that doctors choose to disclose. During the drafting process for SOC-8, WPATH commissioned a study from Johns Hopkins University into whether adolescents had the capacity to consent to medical transition. WPATH abandoned the study prematurely once researchers informed the drafting committee that evidence was likely insufficient to support their claims about the benefits of providing these procedures to children.
WPATH’s own internal communications acknowledge the problem of pediatric consent more directly. As one doctor put it in a leaked recording of a WPATH panel: “We’re often explaining these sorts of things to people who haven’t even had biology in high school yet.” On fertility preservation discussions with fourteen-year-olds: “I know I’m talking to a blank wall… They’d be like, Ew, kids, babies, gross.” Justice Thomas, in his opinion in United States v. Skrmetti, noted that analogizing a teenage patient’s comprehension to a blank wall “should raise serious concerns regarding the patient’s ability to provide informed consent.”
What is even more concerning is that WPATH may have, in some cases, been restraining even more fervent believers—including top Biden officials. Thanks to reporting from the New York Times, we now know that the “science” was never leading the way—political optics were. Admiral Rachel Levine—the highest-ranking transgender-identifying official in the Biden administration—pressured WPATH to strip age minimums from SOC-8. Internal emails show that Levine’s office was not concerned with the safety or long-term health of minors. Instead, they were concerned with “political fallout” and the “onslaught of attacks” from those opposing these procedures. By demanding that WPATH remove age limits for double mastectomies and genital surgeries on fourteen- and fifteen-year-olds, the Biden administration effectively ordered a medical guild to prioritize a PR strategy over patient welfare. WPATH, which the media has long treated as a disinterested scientific body, complied.
When a political appointee is caught pressuring a medical body to lower the bar for irreversible surgeries on fourteen- and fifteen-year-olds, the “evidence-based” label becomes difficult to defend.
The Pipeline
The conflicts of interest go beyond political pressure. Many of the drugs used in these procedures are prescribed off-label, which formally prohibits pharmaceutical companies from promoting them for those purposes. Nonetheless, they have found other ways to cultivate the market. Some—such as AbbVie—donate to political advocacy groups that promote the use of puberty blockers for transgender-identifying minors and support legislation that would make it illegal for doctors to refuse to prescribe them. The pipeline of young patients seeking to become lifelong customers is a business interest worth protecting for these companies.
Databases of payments from pharmaceutical companies to doctors show more connections. In 2018, Endo Pharmaceuticals made payments to Joshua Safer at the Mount Sinai Center for Transgender Medicine and Surgery in connection with one of its puberty-blocker products. Safer is a WPATH board member, an advocate for gender transitions for minors, and a co-author of both the Endocrine Society and WPATH guidelines for transgender care, as well as the transgender hormone treatment sections in UpToDate. He is, in other words, among the most influential figures setting the standards this industry follows—and pharmaceutical companies compensate him accordingly.
Kara Connelly, director of the gender clinic at Doernbecher Children’s Hospital in Oregon, also received payments from Endo, designated for expenses related to Supprelin LA and Lupron Depot, both of which are administered at her clinic as puberty-blocking drugs. Connelly was also a co-author of a paper seeking to refute the findings of the Cass Review, an NHS-commissioned four-year inquiry led by Dr. Hilary Cass, which led the NHS to restrict access to gender transition treatments for minors, including prohibiting the use of blockers for anyone under 18 outside a research setting.
In San Diego, Maja Marinkovic, co-director of the Center for Gender-Affirming Care at Rady Children’s Hospital, was ranked ninth nationally for payments received for Supprelin LA in 2018. Puberty-blocker medications are, according to KPBS, a common treatment at the Rady clinic.
These payments are not always easy to find. In the case of Jeremi Carswell, director of the Boston Children’s Hospital Gender Multispecialty Clinic, the payment appeared in the footnotes of a paper Carswell co-wrote, arguing that puberty suppression could reduce suicidal ideation in transgender youth, against the weight of the evidence. The paper initially ran without disclosing that Carswell “has received an advisory board stipend from Endo Pharmaceuticals.” The omission was corrected only after publication.
Money matters. An analysis by ProPublica found that “doctors who received payments linked to specific drugs prescribed more of those drugs.” On average, “across all drugs, providers who received payments specifically tied to a drug prescribed it 58 percent more than providers who did not receive payments.”
Any of these practices could provide a basis for regulatory or investigative action. The Justice Department could probe whether manufacturers and distributors made false claims about drugs used in gender transition, whether the drugs were prescribed on- or off-label, and whether they were promoted for off-label use. The FDA could investigate the use of these drugs and, if warranted, require warnings or restrict their use.
These practices are so pervasive that imposing even minimum ethical standards could have a significant effect. Florida passed a law limiting cross-sex hormones to adults and requiring in-person visits, signed consent forms acknowledging potential side effects, and prescriptions from licensed physicians. One local Planned Parenthood affiliate subsequently reported an eighty-eight percent decrease in transgender-related visits.
For years, the American public was told to follow the science on the medical transition of children. The experts at WPATH assured us that “gender-affirming care” was evidence-based, lifesaving, and settled. But as Benjamin Ryan’s exposé in Compact and the leaked WPATH Files have demonstrated, these assurances were built on something closer to ideological consensus than clinical evidence.
The internal communications are damning. WPATH members—the people setting the standards followed by the American Medical Association and major hospital systems—privately acknowledged that children are too young to understand the lifelong consequences of the drugs and surgeries being administered to them and that the evidence base for those interventions is often non-existent or of low quality. Yet publicly, they continued to demand that parents and lawmakers defer to their “expertise.”
Outside the United States, the same evidence has produced a very different response. Great Britain, Sweden, and Finland have already moved away from this model, concluding that the evidence simply is not there. The Cass Review exposed a staggering lack of long-term data and a clinical culture of diagnostic overshadowing that consistently failed to identify underlying conditions—autism, trauma, mental illness—before proceeding with medical intervention. European health authorities have concluded that puberty blockers and cross-sex hormones are not a reset button for adolescent distress but a pathway to permanent medicalization. Consequently, they restricted these procedures to closely monitored research settings and returned to a therapy-first model.
The United States remains the outlier. The reason is not better science. A child placed on the path to medical transition represents years of hormone prescriptions, frequent laboratory monitoring, and potentially multiple surgeries—a significant and recurring revenue stream. In a system where facility fees and buy-and-bill markups drive institutional decision-making, there is little financial appetite for the watchful waiting approach that has become standard in Europe. The persistence of these procedures in America has less to do with civil rights and more to do with the economics of a for-profit healthcare system. The science is not, in fact, settled—but in America, the money is talking loudly enough to drown it out.
What is unfolding is not a medical controversy but an institutional failure of the first order. WPATH functions as an ideological lobby disguised as a medical guild, suppressing the evidence that might have stopped it. The pharmaceutical companies are deliberately cultivating the market. The clinicians are proceeding with these interventions, knowing the evidence is weak and the consent inadequate. The political officials who intervened did so not out of concern for children but out of concern for optics. The results are visible in the growing numbers of detransitioners—young people left with permanent physical consequences, lost fertility, and deep regret, failed by every institution that was supposed to protect them.
None of this has stopped the gender industry—drugmakers, providers, doctors, and WPATH—from promoting these procedures as “lifesaving,” and from pressuring parents with the prospect of “a living daughter or a dead son.” They have fought to eliminate minimum age requirements and psychological assessment for these procedures and misrepresented the risks to patients in the process.
Legal action is the most obvious avenue for holding doctors accountable, but litigation is slow, expensive, and demands a great deal from people who have already endured significant physical and psychological harm. Many detransitioners choose to move on rather than pursue it.
Fox Varian’s court victory was a long time coming. But larger accountability is overdue—for WPATH, for the hospital systems that adopted its standards without scrutiny, and for the pharmaceutical companies that cultivated this market. The corrupt medical institutions that allowed ideology to override clinical judgment must be held to account. American children who went through this process deserved better, and the ones coming after them still do.