Alabama Attorney General Stephen Marshall is asking the American Medical Association why it still supports the use of hormonal therapies as treatment for gender dysphoria in children, despite changing its position on sex-change surgeries.
“We thus find it concerning that the AMA continues to support the use of puberty blockers and cross-sex hormones to treat gender dysphoria in minors,” Marshall wrote in a letter to AMA President John Whyte. “The quality of evidence is the same as it is for surgeries: low and very-low quality.”
Marshall warned the AMA’s inconsistencies could be misleading the public and violate Alabama’s consumer protection laws, which state it is unlawful for an organization to represent that “goods or services” have “uses, benefits, or qualities that they do not have,” according to the letter.
“We remain concerned that providers, patients, and their families in our States are being confused or misled by the AMA regarding the safety and efficacy of puberty blockers and cross-sex hormones to treat gender dysphoria in minors,” the letter says.
To avoid a “formal investigation” Marshall asked the AMA to answer a series of questions meant to clarify its position on the use of puberty blockers and cross-sex hormones as treatment for pediatric gender dysphoria, within 30 days.
“While we hope to avoid a formal investigation under our consumer protection laws, we do have concerns that the AMA may be violating those laws,” the letter says.
The AMA recently told the New York Times and other news outlets that “surgical interventions in minors should be generally deferred to adulthood” due to the absence of “clear evidence” supporting their use.
“If you agree that there is insufficient evidence to support using surgical interventions to treat gender dysphoria in minors — as your recent statement indicates — we do not understand how you can find that there is sufficient evidence to support using hormonal interventions to treat gender dysphoria in minors,” Marshall writes in the letter.
“These interventions have not been shown to be any safer for children than sex-change surgeries are, and in fact may be all the more dangerous precisely because they are viewed as not as serious. But hormones can leave a child sterilized just as surely as surgery can,” the letter states.
The AMA’s turnabout came shortly after the American Society of Plastic Surgeons (ASPS) published a February 3 position statement recommending “surgeons delay gender-related breast/chest, genital, and facial surgery until a patient is at least 19 years old,” after reviewing available evidence. The ASPS also pointed out in the statement there is “substantial uncertainty” of the “long-term benefits and harms” of puberty blockers and cross-sex hormones.
Marshall successfully defended Alabama’s law banning sex-rejecting procedures for minors during Boe v. Marshall and through litigation discovered hundreds of pages of documents revealing the political forces informing transgender medicine. This included emails showing former Assistant Secretary of Health and Human Services Richard “Rachel” Levine controversially pressured the World Professional Association of Transgender Health (WPATH) into removing gender surgery age minimums from its clinical guidance, called the Standards of Care Version 8.
WPATH’s clinical guideline, which recommends children receive puberty blockers, cross-sex hormones, and surgeries, has been discredited and heavily criticized for lacking scientific rigor.
A 2025 report from the Department of Health and Human Services on the treatment of pediatric gender dysphoria said the WPATH guidelines were “rated among the lowest in quality” and “have not been recommended for implementation by systematic reviews (SRs) of guidelines.”
“Despite their lack of trustworthiness, for more than a decade WPATH guidelines have served as the foundation of the healthcare infrastructure for gender dysphoric (GD) youth in the United States,” states the report.
Marshall views the AMA’s recognition of a lack of evidence to support child sex-change surgeries as a “tacit acknowledgement” that WPATH’s standards are not “evidence-based,” according to the letter.
The letter asks the AMA if it views the WPATH guidelines as “evidence-based, reliable, and consistent with the best practices of evidence- based medicine.”
