Have concerns about your schools? Check out our Education Toolkits.

Open Letter to the APA

An Open Letter to the American Psychiatric Association Regarding the Publication of Gender-Affirming Psychiatric Care

January 2024

On November 8, 2023, Gender-Affirming Psychiatric Care was released by the American Psychiatric Association’s official publishing house.

We the undersigned strongly support the following Open Letter to the APA. Our letter calls on the APA to explain why it glaringly ignored many scientific developments in gender-related care and to consider its responsibility to promote and protect patients’ safety, mental and physical health.  

On Dec 28, 2023, this Open Letter was sent to the leadership of the APA, asking for a substantive response. We invite you to sign below to support our continued efforts to demand medical and mental health excellence from the APA.

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. 

Sign the Letter


Lauren Schwartz, MD
Board Certified, Psychiatry
Fellow of the American Psychiatric Association
Fellow of FAIR in Medicine

Carrie Mendoza, MD
Emergency Medicine
Director, FAIR in Medicine

Aida Cerundolo, MD
Emergency Medicine
Fellow of FAIR in Medicine

Miriam Grossman, MD
Board Certified, Childhood and Adolescent Psychiatry
Senior Fellow, Do No Harm

Sally Satel, MD
Lecturer in Psychiatry
Yale University School of Medicine

Stanley Goldfarb, MD
Chairman, Do No Harm

Erica E. Anderson, PhD
Clinical Psychologist
Internationally recognized authority on transgender healthcare

Jennifer Lahl MA, BSN, RN
Founder, the Center for Bioethics and Culture

Katherine Prudhomme O’Brien
NH State Representative

Dr. Jillian Spencer
Child and Adolescent Psychiatrist
Queensland, Australia

Erin Friday
Our Duty – USA

Dr. David Bell
Retired Consultant Psychiatrist, Former President, British Psychoanalytic Society

Cyrus Nowrasteh
Film Director, Screenwriter

Dr. Juliet Singer
Consultant, Child and Adolescent Psychiatrist
London, UK

A.W. Rousseau, MD, Emeritus
Distinguished Life Fellow of the American Psychiatric Association

Dr. J
Distinguished Life Fellow of the American Psychiatric Association
Diplomate of the American Board of Psychiatry and Neurology

Dr. Az Hakeem, MBBS, MsC, FRCPsych
Consultant Psychiatrist and Group Analyst
Honorary Clinical Associate Professor UCL Medical School, London, UK

C. Alan Hopewell, PhD, MP, ABPP, BSM
Diplomate, American Board of Clinical Neuropsychology  
Former 2004 President, Texas Psychological Association 
DOD Prescribing Psychologist awarded BSM  
Fellow, American Psychological Association  
Assistant Professor, UNTHSC [RET]

Distinguished Life Fellow of APA

Jane Orient, MD
Internal Medicine

Peter A. McCullough, MD, MPH
Internal Medicine, Cardiology
Dallas, TX

Patrick K. Hunter, MD, MSc
Bioethics, FAAP

Quentin Van Meter, MD, FCP
Immediate Past President, American College of Pediatricians

Richard Bosshardt, MD
Plastic Surgery

January Littlejohn, EdS, LMHC

John A. Petros, MD
Professor of Urology
Emory University

Teresa M. Petros, MD
Urgent Care Pediatrician

Dr. Paul Sullins, PhD
Research Professor, the Catholic University of America
Senior Research Associate, The Ruth Institute

Joanne Sinai, MD, MEd, FRCPC
Clinical Associate, Professor of Psychiatry
University of British Columbia

Anastassis Spiliadis, Psychologist
Systemic & Family Psychotherapist, Registered Supervisor

Nathan A. Solomon, PhD

Natalie Strickland, MD
Anesthesiology, Pain Management

Suzanne Reynolds, PharmD

Kathleen Jennison Goonan, MD
Internal Medicine
Massachusetts General Hospital, Retired

Matthew R. Porter, MD
Fellow of AAFP and Executive Committee of American College of Family Medicine

Cirel Klein, LMSW
Trauma Specialist

Scott S. Field, MD
Pediatrician and Clinical Researcher

Tai Croitoru, PhD
Clinical Social Work

Ann Gillies, PhD
Trauma Specialist

Laura B. Cooper, MD
Retired Pediatrician

Virginia Hatch-Pigott, MD

Aneek Shoemaker, MD
Milton, FL

Melissa Nelson, MD

Kinloch Nelson, MD

Caroline C Jones, Pediatric PA-C

Ethel Minder, LMSW

Kathleen E Finnegan, MA
LPC, Retired

S Bryson Flemming, MD
Asheville, NC

Den A. Trumbull, MD, FCP
American College of Pediatrics

Kimberly A. Vacca, MD, FCP
Pediatrician, ACPeds Board Member

Reni Moon, MD

Emily Econie, PMHNP-BC

Dr. Louise Irvine, MBChB, MSc
General Practitioner
London, UK

Dr. Katie Clyde
Consultant Psychiatrist
Hampshire, UK

Dr. Libby Nugent, DClinPsy CPsychol AFBPS

Dr. Phil Hopley, MRCPsych MD
Consultant Psychiatrist

Dr. Stephen Westgarth, MBBS, MRCPsych, PgDipCBT
Consultant Child and Adolescent Psychiatrist

W. Anthony Gerard, MD FAAFP, FACEP
Emergency and Family Physician

Aaron Kimberly, RN
Mental Health

Jonathan Williams, MD, FACEP

Stephynia Limongello, FNP-C
Still Waters Family Health

Shawn Hayston FNP, MSN,CEN ,EMT-P

Misty L. Dotts, FNP-C
Family Nurse Practitioner, Co-Owner, Faith Family Health, PLLC

Kiara Elly, MD

Victoria Hall, FNP-BC, RN, LMT, PMHNP-S

Whitney F. Jones, MD
Gastroenterologist, CRC Advocate
Upstream Health Strategies, LLC

Cammy Benton, MD
Huntersville, NC

Patricia A Powers, MD
Pediatric Endocrinologist
Whole Health Catalysts, PC

J. Cohn

Axa Carnes, M.Ed
Retired educator, Parent

Frank McClelland, MEd, SpArts
Consultant MDE

Grady B. Core, MD, FACS

Alfonso Oliva, MD, FACS
Plastic and Reconstructive Surgery

Tracy L. Hansen, PhD
Clinical Psychologist

Pamela Garfield-Jaeger, LCSW, MS

Soad Tabrizi, MA MFT
Licensed Marriage and Family Therapist

Dr. Bettina Reiter
Fachärztin für Psychiatrie, Psychoanalytikerin
Psychiatrist, Psychoanalyst

David Kay, MD
Board Certified, Internal Medicine and Cardiology

Staci Kay, AGACNP-BC
Adult and Gerontology Acute Care Internal Medicine

Katherine Welch, MD
Pediatric Medicine

Richard H. Sandler, MD
Gastroenterology, Hepatology and Nutrition
Co-chair, Prolife Council
American College of Pediatricians

Weston Saunders, MD
Gastroenterology, Hepatology and Nutrition
Co-owner, Robinhood Integrated Health
Medical Director North Carolina Physicians for Freedom

Y. Rosebraugh, LCSW
EMDR Certified

Bethany Rife, MD

Kristen Walsh, MD

Mark Hoch, MD, MDiv.

Linda W. Flower, MD

Lindsay Jordan, MD

A.A. Howsepian, M.D., Ph.D.
Clinical Professor of Psychiatry, University of California, San Francisco – Fresno Medical Education Program

Patrick Clarke

Roberto D’Angelo

Octavian M. Belcea, MD

Stephanie Winn, LMFT
Licensed Marriage and Family Therapist

Marcy Willows, PhD, MPH

Jane Clare
Registered Nurse

Sara Stockton, LMFT
Licensed Marriage and Family Therapist

Christian Shield, MD

Mark Mierzejewski

Clayton J. Baker, MD
Board Certified, Internal Medicine; Clinical Associate Professor of Medical Humanities and Bioethics, University of Rochester, 2012 – 2018

David W Morgan BSc MB BCh LLM FRCPC
Forensic Psychiatrist in private practice; Clinical Associate Professor, University of British Columbia

Julia Mason, MD

Marcus Evans

Susan Evans
Psychoanalytic Psychotherapist

Jim Lightfoot
Concerned Citizen

Kathleen Dooley
Attorney and Concerned Parent

Kathleen Mulligan
Concerned Parent

Rebecca Simpson
Concerned Parent

Professor Jordan B. Peterson
University of Toronto

Karl Benzio, MD
Board Certified Psychiatrist
AACC Medical Director
Honey Lake Clinic Co-founder and Medical Director
American Association of Medical Ethics NJ State co-Director

Kristopher Kaliebe, MD 
Professor, Department of Psychiatry and Neuroscience, University of South Florida, Member, American Psychiatric Association, Board certified in Psychiatry
Child and Adolescent Psychiatry and Forensic Psychiatry

Sasha Ayad, MEd, LPC
Licensed Professional Counselor, Author
Inspired Teen Therapy, Gender a Wider Lens Podcast

Wendy Rogers, MSW
Arizona Senator

William Braden, MD
Distinguished Life Fellow, American Psychiatric Association

Laura Dunn, MD
Chair, Department of Psychiatry

Andre van Mol, MD
Family Medicine

Paul W. Hruz, MD, Ph.D
Associate Professor of Pediatrics

Erin Everitt
President of Advocates Protecting Children

Dr. Jeff Barrows
Senior Vice President, Christian Medical & Dental Associations

Allan Josephson, MD
Past Chair Committee on Family
American Academy of Child and Adolescent Psychiatry

Lisa Marchiano, LCSW

Colin Wright, PhD
Evolutionary Biology

Jamie Reed, MS
Clinical Research

Stella O’Malley
Psychotherapist, Author, Speaker
Genspect, Gender: A Wider Lens Podcast

Jill Simons, MD, FCP
Executive Director, American College of Pediatricians

Renée S. Kohanski, MD
General & Forensic Psychiatry
Diplomate of the American Board of Psychiatry & Neurology, Diplomate of the National Board of Physicians & Surgeons

Michael K. Laidlaw, MD

Christopher H. Rosik, PhD
Licensed Psychologist
Fresno, CA

Laura Macnow, MD
Emergency Medicine

Christine Henrichs, MD
Family Medicine

Jeremy Henrichs, MD
Family Medicine

Marilyn M. Singleton, MD

Erica E. Li, MD

Diana Blum, MD

Stewart L. Cooper, MD
Internal Medicine

Mark McDonald, MD
Adult, Child, and Adolescent Psychiatry

Kenneth J. Marks, DO
Psychiatrist, Board Certified / ABPN

Elliott Kaminetzky, PhD
Licensed Psychologist
Founder and Clinical Director The Center for Child Behavioral Health

Pinchas Herszberg
Dip. Couns. Children and Young Adults, Organisational Psychotherapist

Nancey Trevanian Tsai, MD

J. Lee Pace, MD
Orthopedic Sports Medicine

Malka Miller, PsyD

Kristen Farrell-Turner, PhD
Licensed Psychologist

Robert E. Jackson, MD
Family Medicine, AAPS

Erica Weinstein, LCPC, CCTP

Victor Chen, MD

Malkie Davidson, PsyD
Child and School Neuropsychologist

Sheila Furey, MD
Child and Adolescent Psychiatrist

V. L. (Bob) Cantrell Ph.D.
School Psychologist III (Expired and Retired)
Nationally Certified School Psychologist, (Expired and Retired)
Licensed Psychoeducational Specialist, (Expired and Retired) 

Joshua Halle, PsyD
Child and Adolescent Psychologist

L. David Perry, MD
General Pediatrics

Laura Haynes, PhD
For the International Foundation for Therapeutic and Counseling Choice, U.S.A. Country Representative

Thomas J. Schreiner, MD 
General Pediatrics

Michael Milgraum, Esq, PhD
Licensed Psychologist, Mental Health

Michelle Mackness, BA, MC
Clinician and Life Coach

Michelle A. Cretella, MD
Co-Chair Adolescent Sexuality Council of American College of Pediatricians

Ronald E. Kramer, MD

Marcie Foster, LISW-S
Perinatal Mental Health, Women’s Mental Health, and Teenagers & Young Adult life changes

Joseph Guarino, MD, MPH, FACOEM
Occupational Medicine

Jessica Bishop, DDS

Edward F. Drass, MD
Family Practice and Internal Medicine
Cape Coral, FL

Jane E. Anderson, MD

Dianna Lightfoot
White House Appointee, USAID-Global Health (2017-2021)

Gretchen A. Reis, MD
Family Medicine, Integrity Wellness MD

Ralph E. Carter, MD

Sarah M. Carter, RN

Rebekah Corley, LCSW

Kevin L Speight, MD, MBA

Anonymous, MD
Pediatric Emergency Medicine

Anupam K. Singhal, MD
Dallas, Texas

Laura Haygood, MD
Board Certified Dermatologist

Thomas C. Wiener, MD
Plastic Surgery, Past president Texas Society of Plastic Surgeons, Past President Houston Society of Plastic Surgeons

Kristen Hawthorne, MD

Duren Michael Ready, MD 
Family Medicine Physician

Jon Ward, MD 
Associate Professor, Dermatology, Alabama College of Osteopathic Medicine

Leonora Regenstreif, MD

Lili Daoud, LCSW
Supervisor, Training Faculty
Albert Ellis Institute

Abraham Daoud, MD
Retired Surgeon

Bose Ravenel, MD, FAAP
Pediatrician, Retired

William M. Barrett, MD

Baruch Schmidt, MD
General Surgery

Jack Clinton, MSW, LISW-CP

Mary M Kennedy, PsyD

Christi Pramudji, MD

Sarah Dietrich, MD

M. Thomas Beets, MD, FAAFP

Kelly Hess, LPC Associate

Alesha Logan, NP

Michele Bachman, MA, LPC-S

Joslin Batty, LCSW

Mary Kay Lowe, MA, LMFT 

Jasmina Cesic
Author, Parent

Robert W. Otto, PhD
SDG Counseling, LLC

Derek Husmann, MD

SC Benoit, PhD, LPCC-S
Licensed Clinical Counselor and Educator, Specialties: Obesity, Eating disorders, Addictions, Existential and Faith based counseling

Brian Walsh, MD, MBA

Anne J. Ryland, PA

Rhonda K. Velders
Licensed Professional Counselor-Supervisor
Illuminated Pathways Family Therapy, LLC, Owner

Margaret Brody, MD
Child Psychiatry, Retired Status

Nicole M. Johnson, MD
Pediatrics Critical Care
Parents for Accountability in Cleveland Independent Schools

Victoria Schneider, MD
General Pediatrics

Susan Schmidt-Lackner, MD
Board Certified Adult and Child Psychiatry

Jeremy Simms
Clinical Psychologist

David W Morgan BSc MB BCh LLM FRCPC
Forensic Psychiatrist in private practice; Clinical Associate Professor, University of British Columbia

Daniel D. Pugh MD
Associate Professor of Psychiatry, retired, Washington University in St. Louis.

Rebecca Shiner
Charles A. Dana Professor of Psychological and Brain Sciences

Charles W. Thompson II
Concerned Citizen

Lorraine Gari, MD

S Bandyopadhyay

Lynda Hillman, DNP, ARNP
Nurse Pratcitioner

Jason Chaffin

Dr. Arnout ter Schure

Natalie McAfee, RN

Karen Hernandez, PhD
Marriage and Family Therapy

Paul Church, MD
Retired Urologist and former Assistant Clinical Professor of Surgery
Harvard Medical School

Eithan Haim, MD
General Surgeon, Whistleblower

D Garland
Community Activist

Greta Clinton
Concerned Grandparent

Sign the Letter

Additional Signatories: