We are a group of clinicians, educators, and researchers committed to treating every patient with respect and compassion while upholding excellence in medical and mental health care. We seek an unbiased scientific investigation and discussion of the harms and benefits of all types of care offered to those with gender related distress. We have grave concerns about the American Psychiatric Association’s GAPC textbook. Until those concerns are addressed and the textbook’s errors corrected, we call on the APA for its withdrawal. 

GAPC, released on November 8, 2023 by the American Psychiatric Association’s official publishing house, is touted as “the first textbook dedicated to providing affirming, intersectional, and evidence-informed psychiatric care for transgender, non-binary, and/or gender-expansive (TNG) people.” APA Publishing claims to use a system that “is unique in the extent to which it uses peer review in both the selection and final approval of publishing projects.”  Considering the serious concerns about “affirming care” of minors raised by multiple international systematic reviews, we do not understand how such a review process could grant the imprimatur of the APA. We ask that APA Publishing disclose details of the peer review process for this book and explain why it glaringly ignored scientific developments in gender-related care. 

The book’s claims of being evidence-informed are untenable. GAPC omits any in-depth analysis of the evidence to date, dismisses “scientific neutrality” as “a fallacy” (p. xix), and chooses authors with the correct “lived experiences” and “community impact of prior work over academic titles” (p. xx).   

At the time of publishing, the gender affirmation model promoted in GAPC is under scrutiny from clinicians and scientists worldwide. After conducting careful systematic reviews of the evidence, Finland, Sweden, and the United Kingdom are drastically retrenching from their earlier affirmation model for treating gender dysphoria in minors. In Norway, the Netherlands, Denmark, France, Australia and New Zealand we see either critical reviews by public health agencies, or pushback by professional societies and in mainstream medical journals. Having omitted these international developments and heated debates, GAPC was out of date before its publication.  

Not only do the authors ignore the most current systematic reviews, which count as the most reliable source of scientific information in evidence-based medicine, they also repeatedly undermine well-established standards of care in multiple mental and medical practices. We highlight just two examples of many.  

First, GAPC neglects to address the many known risks of puberty blockers (see Cass Review 2020, Jorgensen et al. 2022, FDA 2022), and cross-sex hormones while presenting fundamentally flawed research to support their gender-affirmative approach. The authors falsely state that “Use of GnRHas in pubertal suppression is a fully reversible intervention that allows young patients time to mature, explore their gender identity, and understand better the risks and benefits of GAHT” (p. 52). It is astonishing to see such an outdated fallacy appear in this book, especially referring to a case presentation of a 10-year-old child. According to Jorgensen et al. 2022, “Over 95% of youth treated with GnRH-analogs go on to receive cross-sex hormones. By contrast, 61-98% of those managed with psychological support alone reconcile their gender identity with their biological sex during puberty.” This contradicts both the reversibility and exploratory nature of puberty suppression claimed by GAPC.  

The authors continue, “This often leads to improvement in psychiatric symptoms, behavioral problems (de Vries et al. 2011), and suicidal ideation (Turban et al. 2020)” (p. 52). The studies cited by the authors have been extensively critiqued by the aforementioned reviews and other investigators (see Biggs 2022, SEGM 2023, Abbruzzese et al. 2023). The European systematic reviews found the de Vries study to be at high risk of bias. The Turban et al. study is cross-sectional, and by the authors’ own admission “does not allow for determination of causation. Longitudinal clinical trials are needed to better understand the efficacy of pubertal suppression.” Additional, equally profound critiques include a) downplaying serious known side effects b) profound methodological flaws that exaggerate and misrepresent reported efficacy and benefits c) inclusion of only the most successful cases in outcome-reporting d) lack of applicability to the currently predominant cohort of minors experiencing gender dysphoria (adolescent-onset natal female patients with severe psychiatric comorbidities) and e) absence of randomized, controlled trials and long-term studies (Ludvigsson 2023).

Second, the authors are disturbingly nonchalant about the high rate of co-occurring mental and behavioral health challenges seen in the context of gender dysphoria. Autism, ADHD, eating disorders, anxiety, depression, suicidality, substance use disorders and obsessive-compulsive disorder are all dramatically over-represented in gender dysphoric youth. The Minority Stress Model is used to dismiss such phenomena, unscientifically, as the result of “the psychosocial stressors associated with having to exist within a cisheteronormative society” (p. 50). Minority stress is not sufficient to explain away all psychological distress in the gender nonconforming population, as research has shown no significant change in suicide rates over time in this cohort despite increasing societal acceptance. Rather than comprehensively exploring and addressing these co-occurring conditions, GAPC charges ahead with medicalized gender transition in children and young adults with autism and ADHD (chapter 8), substance use disorders (chapters 1, 13 & 16), eating disorders (chapter 15), and severe mental illness (chapter 18).  

GAPC overlooks the risk that rapid affirmation concretizes patients’ dysphoria or contributes to patients’ regret post-treatment, with some even attempting to return to their natal sex. Such detransitioned individuals are now suing surgeons, endocrinologists, and psychiatrists for damages, claiming their doctors encouraged them to follow measures that are not backed by rigorous science and did not address their co-morbid conditions. They are suing health systems employing such doctors and the professional organizations (the American Academy of Pediatrics in the Isabelle Ayala lawsuit) that uncritically endorse unproven and irreversible treatments. It appears that the APA is either unaware of or has chosen to ignore such risks and outcomes for patients and for those that promote, teach and provide these treatments. 

GAPC condemns any attempt to prevent such iatrogenic harm through careful evaluation, wrongly dismissing widely-accepted, less invasive psychotherapeutic treatments as “conversion therapy” (p. 291). Instead, GAPC proposes that patients struggling with gender-related distress be taken at their word that “gender” is the source of the problems and rushed to treatments that may lead to irreversible sterility, anorgasmia, surgical complications, and life-long dependence on exogenous hormones and medical interventions. This aggressive approach discounts the possibility that many of these children, if not initiated on blockers and hormones, would eventually conclude that their early gender dysphoria was the developmental prelude to a healthy, non-heterosexual adult orientation.

The American Academy of Pediatrics (AAP) has similarly advocated for gender-affirming care by publishing a policy statement in 2018, a stance it recently reaffirmed. The AAP now finds itself named in the Ayala case, cited above, on claims that it improperly endorsed harmful care that is not backed by evidence. Its publishing house was accepting pre-orders for a book promoting gender-affirming care until December 6, 2023 when the book was removed, with refunds offered, pending further review. We hope the APA heeds the AAP’s example and retracts GAPC. 

Encouraging any physician, trainee, program or provider to view this book as “cutting-edge” “best practices” is unacceptable, unethical and unsafe. We urge APA Publishing to consider its responsibility to promote and protect patients’ safety and their mental and physical health, and to uphold its own claim to be “the world’s premier publisher of books, journals, and multimedia on psychiatry, mental health, and behavioral science”. To avoid discrediting itself as a professional organization and a reliable source of gender related psychiatric care, and to minimize the risk of legal liability to itself, we call on the APA to withdraw this book.