Alabama Attorney General Steve Marshall called for greater restrictions on gender affirming care procedures for minors on Monday.
The attorney general, who has been a vocal opponent of gender-affirming care for transgender minors, highlighted a letter sent last week on behalf of 20 states to the American Medical Association commending the organization for its recent opposition to surgical procedures for trans youth.
Additionally, the letter urges the AMA to publicly oppose the use of hormonal procedures and puberty blockers for transgender minors, threatening investigation for potential violations of state laws if the organization does not disavow the treatments.
In early February, the AMA followed the American Society of Plastic Surgeons in declaring “that surgical interventions in minors should be generally deferred to adulthood.” The organizations mark the first two major medical groups that have backed limitations on gender-related surgeries for minors, drawing praise from the Trump administration and U.S. Department of Health and Human Services leadership.
“The American Medical Association has finally admitted what many have warned for years: its recommendations for surgeries on children were not grounded in solid evidence, despite telling doctors and families otherwise,” Marshall said in a statement released Monday.
“Yet the same weak science underpins puberty blockers and cross-sex hormones. You cannot dismiss one intervention as unsupported while continuing to push the rest,” the attorney general continued. “When children’s lives and futures are at stake, anything less than full scientific honesty is reckless. The AMA must follow the science completely, not selectively.”
The change in AMA and ASPS treatment guidelines was based on a 2025 HHS report entitled “Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices.”
The letter cites that the HHS report found that evidence was uncertain that puberty blockers and hormone treatments improve transgender minors’ mental health and safety, and may cause infertility when administered to some patients going through puberty.
“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. The quality of evidence is the same as it is for surgeries: low and very-low quality,” the letter reads.
The HHS study, the original version of which was drafted in 90 days in response to an executive order entitled “Protecting Children from Chemical and Surgical Mutilation,” was met with criticism from LGBTQ+ advocacy and medical researchers upon its release in May 2025.
The report only listed the name of one of its nine authors and did not include peer reviews of its findings. An updated version of the study was released last November, including the names of its authors, peer reviews and editorial and citation corrections.
Original peer reviews of the study, while largely reflecting positively on its conclusions, critiqued the report’s neutrality, with the American Psychiatric Association writing that it “fails to address the risk of confirmation bias.”
Peer reviewer and Dutch postdoctoral researcher, Jilles Smids, while describing the report as “well-argued,” wrote that “It is clearly not a neutral report in the sense of merely providing the relevant considerations for and against the current gender affirmative treatment model,” and that the report “decidedly argues against early medical intervention for [gender dysphoria] in minors.”
The HHS paper and AMA and ASPS decisions regarding gender-affirming treatments also rely upon the Cass Review, an independent report on gender identity services in the U.K. that has received criticism from the APA and medical researchers “for its methodological flaws and biases.”
The letter urges the AMA against compliance with standards of care presented by the World Professional Association for Transgender Health, WPATH, condemning the organization’s research methodology as biased in favor of gender-affirming medications and procedures for minors and not “evidence-based.”
The signed attorneys general further justified their request that the AMA endorse restrictions on puberty blockers and hormones for minors based on policies enacted in the U.K. and Norway in response to the Cass Review.
The document goes on to warn that the AMA could subject itself to investigations for potential violations of consumer protection laws by not disavowing puberty blockers and hormone treatments for minors and asks the organization to clarify its stance on the treatments, including whether it follows WPATH’s latest standards of care.
Alabama’s Consumer Protection Act prohibits organizations from representing “benefits” or “qualities” that they do not possess or “false, misleading, or deceptive” business acts.
“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 reads.
While Marshall praised AMA and ASPS for the shifts in their recommendations on gender-affirming care guidelines, alongside Alabama Republican lawmakers such as U.S. Sen. Tommy Tuberville, R-Ala., U.S. Rep. Robert Aderholt, R-Ala., WPATH and the American Academy of Pediatrics have released statements declining to provide blanket guidelines for or against youth gender-affirming care medical procedures.
“As the leading global professional organization for clinicians, researchers, and experts in the field of transgender healthcare, WPATH and its U.S. affiliate, USPATH, continue to support the Standards of Care’s cautious guardrails and criteria provided for adolescents to access surgical care,” the organization wrote.
“These guardrails acknowledge that there is no definitive age or ‘one-size-fits-all’ approach for every patient, which is why they are built on case-by-case assessments, involve experts on adolescent development, and are designed to support thoughtful and ethical shared decision-making in a multidisciplinary field,” WPATH added.
Currently, 27 U.S. states, including Alabama, have implemented bans on gender-affirming care procedures for minors.
In addition to Marshall, the letter received signatures from the attorneys general of Arkansas, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Nebraska, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas and West Virginia.
