Mark Hyman Rapaport, M.D.
President
American Psychiatric Association
800 Maine Ave SW
Washington, DC 20024
Dear Dr. Rapaport:
The Department’s landmark report “Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices,” initially released on May 1, 2025, and finalized on November 19, 2025, documented substantial evidence of harm for minors from sex-rejecting procedures.1 The contributors are a wide range of medical professionals and academics who found that the harms of these procedures, namely, puberty blockers, cross-sex hormones, and surgical operations, outweigh any perceived benefits. The HHS Review underwent an extensive peer review process—umbrella review—soliciting feedback from medical professionals and organizations.
The overwhelming consensus among the peer reviewers is that the conclusions drawn in the HHS Review are gold standard science.
It is this administration’s priority to end all sex-rejecting procedures on minors, ending the severe and irreversible harm caused by these procedures. The harm portfolio for these interventions includes, “infertility/sterility, sexual dysfunction, impaired bone density accrual, adverse cognitive impacts, cardiovascular disease and metabolic disorders, psychiatric disorders, surgical complications, and regret.”2 The Department has since acted to end sex-rejecting procedures on minors, including by ending federal Medicaid and CHIP funding of sex-rejecting procedures on minors.3
In recent years, the use of sex-rejecting procedures in the United States has grown significantly, while European countries, who were initially the leaders in this space, have limited these procedures due to international concerns about the evidence, efficacy, and safety of chemical and surgical mutilation.
One would expect that an organization holding itself out as a steward of national medical standards and claiming to place the health and safety of children above all else might have something to say when the evidence calls its guidance into question. Yet, the APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM) has not been updated to reflect international consensus or the current evidence-based showing the harms of these interventions. In fact, you currently maintain on your website,
The term “transgender” is not a psychiatric diagnosis. It is used to refer to a person whose sex assigned at birth (usually based on the appearance of external genitalia) does not align with their gender identity (one’s psychological sense of their gender). Some people who identify as transgender do experience “gender dysphoria,” a DSM-5-TR psychiatric diagnosis that refers to the psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity.
In February, the American Society of Plastic Surgeons (ASPS) followed the science by updating their position on sex-rejecting procedures on minors.4 ASPS found that the evidence base supporting sex-rejecting procedures to be “low quality/low certainty” and that “there is insufficient evidence demonstrating a favorable risk-benefit ratio for the pathway of gender-related endocrine and surgical interventions in children and adolescents.”5
This letter serves as a request for the following:
- A clear, current statement of the APA’s position on sex‑rejecting procedures for minors and clinical diagnosis for minors struggling with their sex;
- Identification of updates, revisions, or corrections to APA’s DSM;
- A concrete timeline for any forthcoming changes.
The Department expects your written response within 10 business days. Silence will speak for itself as a choice to place commitments to radical ideology ahead of evidence-based medicine and the children APA claims to protect.
Sincerely,
/s/
Robert F. Kennedy, Jr.
Footnotes
1 U.S. Department of Health and Human Services, Gender Dysphoria Report, https://opa.hhs.gov/gender-dysphoria-report.
2 U.S. Department of Health and Human Services, Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices, November 19, 2025, https://opa.hhs.gov/sites/default/files/2025-11/gender-dysphoria-report.pdf.
3 HHS Ends Federal Medicaid and CHIP Funding for Sex-Rejecting Procedures for Children and Youth, https://www.hhs.gov/press-room/hhs-ends-medicaid-chip-funding-sex-rejecting-procedures-children.html
4 U.S. Department of Health and Human Services, HHS Leaders Commend the American Society of Plastic Surgeons for Disavowing Pediatric Sex-Rejecting Procedures, https://www.hhs.gov/press-room/asps-gender-dysphoria-statement.html.
5 American Society of Plastic Surgeons, Position Statement on Gender Surgery for Children and Adolescents, https://www.plasticsurgery.org/documents/health-policy/positions/2026-gender-surgery-children-adolescents.pdf.