Scientific Evidence, Language, and Social Experience in Clinical Guidelines
Challenges of moving beyond the gender-affirming paradigm for children and adolescents. By Nicolás Raveau.
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After seven years of systematic reviews, the “gender affirmation” model faces a crisis of scientific and social legitimacy. This essay analyzes the global shift toward clinical caution, taking Singapore’s recent guidelines (May 2026) as a case study, and shows the conceptual dissonance that persists in health manuals, where activist bibliography contradicts the prudence of the new medical recommendations.
If anything has been firmly established after the systematic review of gender-affirming clinical guidelines during the last seven years, it is the low quality and profound uncertainty of the scientific evidence that supported them1. Following the path of pioneering countries —such as England, Sweden, and Finland—a growing list of jurisdictions that includes Denmark, Norway, France, Chile, Brazil, the province of Alberta in Canada, the state of Queensland in Australia, and more than twenty-five U.S. states have reoriented their health policies. These measures are not an ideological impulse, but a technical adjustment grounded in Evidence-Based Medicine (EBM), restricting access to hormonal interventions in children and adolescents identified as trans and prioritizing instead psychotherapeutic support and social accompaniment.2
This trend toward caution has recently been reinforced by guidelines from Singapore’s Ministry of Health, which aligned its health regulations with the European benchmark in May 2026. Its new treatment guidelines emphasize a safeguarding and psychological exploration approach over immediate medicalization3. However, as the specialized site Gender Clinic News warns, these guidelines still employ “some affirmative language,” even as critical studies of that same approach coexist.4 This phenomenon reveals a conceptual dissonance that is not exclusive to Asia but also permeates the European references themselves.
Specifically, what the Singapore guidelines lack is internal coherence. Their bibliography constructs a linear narrative from authors with antagonistic theoretical frameworks. For example, the pediatric guidelines cite both Steensma and de Graaf — the architects of the original Dutch protocol, whose 2006 study was funded by a puberty blocker manufacturer — alongside Bonifacio and Rosenthal, prominent advocates of immediate affirmation. This mix results in a document that sounds prudent in its recommendations but remains anchored in transactivist sources.5
The problem is that when childhood identity exploration places “gender” at the center, it narrows the focus and undermines a holistic perspective aligned with developmental stages. Prioritizing this variable ignores how cognitive structures develop progressively, as described by classical developmental psychology (Piaget, Erikson). Introducing concepts such as “consistent gender identity at age 6” (p. 3 of the Singapore document) into processes that are, by nature, fluid and non-definitive constitutes a reductionism that psychologist Jonathan Haidt has recently linked to the over-intellectualization of identity in digitalized childhood.6
This terminological inheritance —the use of concepts such as “non-binary” or “agender” in children— persists even in countries that have taken a step back. In Finland and Sweden, bureaucratic inertia persists: the core texts urge caution, yet the bibliographies still rely heavily on WPATH’s glossaries, which are steeped in queer theory and social constructivism. Even the Cass Review uses “clinical etiquette,” addressing minors with their preferred pronouns and identity labels to preserve the therapeutic bond, even though the body of the report itself dismantles the validity of these interventions.7
Singapore continues to rely on the DSM-5 (2013) and DSM-5-TR (2022) as its main diagnostic standards. Yet the Cass Review has made an important correction: diagnosis must go beyond simply ticking symptom boxes. The DSM-5 criteria for childhood gender dysphoria (pp. 452-453) still use outdated stereotypes — for example, preference for dolls, rough-and-tumble play, or sitting to urinate — as evidence of a trans identity. This rigid checklist replaces one set of gender stereotypes with another and fails to fulfill the core duty of clinical care: providing a genuine, holistic understanding of the child.8
The DSM-5 stands accused of adopting queer theory without sufficient scrutiny, incorporating ideas driven more by politics than by biological or social reality.⁹ At the same time, activism that claims to “depathologize” gender dysphoria supports the use of drugs with serious side effects in 8- and 10-year-old children. The result is a manual that applies simplistic criteria while remaining anchored in elaborate queer concepts — ultimately placing ideological control above scientific rigor.9
Health service users, families, and detransitioners have much to say, but their voices are frequently overshadowed by hegemonic activism. It is imperative that the “data” (scientific evidence) and the “narrative” (social experience, language) walk hand in hand once more. The central challenge of this paradigm shift is to examine the origins and validity of the terms we currently use. The goal is not to question the existence of people who experience distress, but to challenge the dominant conceptualization that turns normal discomfort with one’s developing body into a medical condition.
The Singapore adolescent guide prioritizes parental agreement over diagnosis (p. 11), a measure that favors family safeguarding. Likewise, in May 2026, the British Medical Association (BMA) withdrew its opposition to the Cass Review, recognizing its methodological rigor despite prior activist harassment that forced anonymous voting for fear of reprisals.10
Could the implementation of clinical caution be advancing slowly due to two factors: the silence forced by the threat of “funa” or activist harassment, and persistent terminological confusion? As Swedish pediatrician Mats Reimer warns, despite prudent policies, some clinics continue to operate under the previous model due to inertia11¹¹.
Those of us seeking alternatives to the gender-affirming model face the challenge of discussing these terminological differences without fear. Not conforming to gender stereotypes or social expectations is not a valid reason to subject children to risky medical interventions and unproven treatments. Courage and caution are not opposites. Today, more than ever, they form the foundation of ethical practice in child mental health.
Nicolás Raveau is a detransitioner and researcher in health, transition, and detransition based in Chile.
detranschile@gmail.com | https://linktr.ee/detrans_chile
This article was originally published by Raiz Humana
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Affirmative psychotherapeutic approach: A model that prioritizes the immediate validation of the subjective narrative, reducing therapy to a gateway for medicalization and attributing any distress to “minority stress.”
For an example of this sequence in Chile, see: https://www.ciperchile.cl/2024/06/25/evidencia-experiencia-y-cartas-transafirmativas-las-contradicciones-del-programa-crece-con-orgullo/
Trans-identified (participle): This term is preferred to indicate that the category is often the result of external coding or influence (family, social networks, or institutions) on nonspecific developmental distress.
Both documents are dated July 2025, but were made known internationally through a circular from Singapore’s Ministry of Health dated May 5, 2026. The adolescent guide also states that the pediatric document is from 2024, which is probably an error.
Singapore joins the cautious club, Gender Clinic News, 6 May 2026.
For a good summary of the issues with the Dutch protocol, by the author, see section 1.3 (“Orígenes de la transición médica orientada a NNA), pp. 28-29, in the 2025 redesigned version of the study: Problemáticas de salud y acompañamiento social "género-afirmativo" orientado a menores de edad: conceptos, prácticas y alternativas
The Anxious Generation: How the Great Rewiring of Childhood Is Causing an Epidemic of Mental Illness, by Jonathan Haidt (2024). See also the companion movement site.
The Cass Review: Independent Review of Gender Identity Services for Children and Young People – Final Report, April 2024. Archived version available at: https://webarchive.nationalarchives.gov.uk/ukgwa/20250310143933/https://cass.independent-review.uk/home/publications/final-report/
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) (2014). Spanish edition: Manual Diagnóstico y Estadístico de los Trastornos Mentales, 5ª Edición, available at: https://www.federaciocatalanatdah.org/wp-content/uploads/2018/12/dsm5-manualdiagnsticoyestadisticodelostrastornosmentales-161006005112.pdf (pp. 452-453)
Sexuality and Gender collection, The New Atlantis, https://www.thenewatlantis.com/collections/sexuality-and-gender
“Puberty blockers: BMA critique vindicates Cass review but questions government ‘overreach’”, The BMJ, 6 May 2026, https://www.bmj.com/content/393/bmj.s876
Bernard Lane, “Gay History Hijacked,” Gender Clinic News, 27 April 2026