A few days ago, the Times of India gave me the opportunity to publish an op-ed, making the case for why India should follow the emerging international consensus, and restrict paediatric gender affirming care (GAC).
The op-ed, published in the January 4th Sunday edition, is available here.
I am very grateful to ToI, for making space for an evidence-based discussion of gender medicine, written from a sex-realist perspective.
The piece has provoked strong condemnation from Indian GAC advocates, nasty social media comments, and so on.
I do appreciate that some of the critiques were polite and civil, and referenced research that supports GAC. However, in healthcare regulation, we need to consider the entire body of scientific knowledge and evidence, including the studies with unfavorable outcomes.
Critics have rightly pointed out that the op-ed didn’t have citations. I have added all data sources and links in this blog post. If I get another print media opportunity, I will be more prepared, and publish online citations concurrently!
I also agree that a key limitation is my usage of Indian data on general GAC, and not specifically paediatric GAC. I was unable to find Indian data on GAC for minors, and would appreciate suggestions to pursue.
To the parents of teenagers with Rapid Onset Gender Dysphoria (ROGD) who have reached out, worried about their children: I want to point you to Genspect, which has fantastic resources for parents and families. If you are seeking mental health support for your child, I want to caution you that India’s ‘conversion therapy’ ban deters therapists from offering exploratory psychotherapy.
To the young GAC users who have written to me: I read each of your stories carefully. I share your belief that India’s gendered expectations can be stifling, and that Indian society should be more permissive of gender non-conformity.
When it comes to medical treatments to assuage distress, however, you deserve ethical, evidence-based medicine. To choose the right path for yourself, it is important that you have access to genuine informed consent, with a full understanding of the short-term and long-term risks and benefits. My hope, through my writing, is to surface that information.
Warmly,
Janhavi Nilekani
My view that paediatric gender medicine should be either banned or heavily restricted in India is based on systematic evidence reviews and policy developments from multiple countries and public health authorities.
I frequently reference two authoritative sources, abbreviated as CR and HHS. I recommend both to readers who are seeking a broad overview of what paediatric GAC entails of, current global policies, and the evidence base for GAC.
CR: The landmark Cass Review was commissioned by the NHS England and published in April 2024. The review took four years, included a series of independent systematic reviews of existing evidence, and has been influential around the world.
The final Cass Report 2024 can be found here and an excellent summary is available here.
HHS: Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices is a November 2025 report by the U.S. Department of Health and Human Services and is available here. This is an umbrella review of existing international evidence reviews, including from the UK, Sweden, and Finland. The executive summary within the report is clear and easy to read.
I. Paediatric GAC is increasingly restricted internationally
United States: New York Times, December 2025: House Passes Bill to Ban Gender Transition Treatments for Minors; KFF Policy Tracker, accessed January 2026: 27 states limit youth access to GAC
Restrictions in UK, Finland, Sweden, Norway, Brazil, Chile, Alberta in Canada, Queensland in Australia: Citations and details available in HHS pages 63-65
II. India is expanding access to gender-affirming care
Private-sector growth of GAC
Cognitive Market Research estimates approximately 16% compound annual growth rate (CAGR) for ‘sex reassignment surgery’ in India between 2026 and 2034
Mordor Intelligence projects a 10.6% global CAGR for ‘sex reassignment surgery’ in 2026-2031, and 11.62% for Asia-Pacific, with growth driven in part by markets such as India and Thailand.
Strategic Market Research anticipates a 15.3% CAGR in Asia-Pacific between 2024-2030, in part due to growth in India.
Public-sector provision
AIIMS Bhopal has established a Transgender Health Clinic providing hormonal and surgical services.
Ayushman Bharat (PM-JAY), India’s flagship public health insurance program, includes coverage for gender-affirming surgeries and other types of care.
Government hospitals in Tamil Nadu, Kerala, etc provide GAC.
Caveats
As mentioned earlier, data specifically on paediatric GAC is not available. In general, however, the GAC market is growing and gaining institutional legitimacy, without clear paediatric-specific safeguards or restrictions.
The data is mainly for ‘sex reassignment surgeries’, I have not been able to find good quality data on usage of hormone treatments or puberty blockers.
III. Overview of gender-affirming care
Foreword and executive summary of the HHS Report, pages 9-16
HHS page 21 specifically covers GAC protocols in minors - puberty blockers from as early as 8 or 9 years, followed by cross-sex hormones, with surgeries usually later
IV. There is no strong evidence that GAC improves long-term psychological health or lowers suicide risk in adolescents
No robust evidence of long-term mental-health improvement
HHS pages 94-95
CR pages 176-177, pages 184-186
No reliable evidence of reduced suicide risk
HHS pages 74-77
CR pages 94-96, pages 186-187
Appleby Report 2024, commissioned by the UK government to inform policy
V. The evidence of harm is substantial
Fertility and sexual function
HHS pages 119-126
CR page 178
Long-term physiological development
HHS pages 113-117, page 123, pages 127-128
CR page 177-179
Impaired bone density
HHS pages 117-118
CR page 178
Cardiovascular effects
HHS page 126-128
Neurocognitive development
HHS page 118-119
CR page 178
VI. Around 80% of children diagnosed with gender dysphoria reconciled with their sexed bodies as puberty progressed, in the era before medical transition
The wide body of literature on this subject is summarised on CR pages 67-68
VII. Almost all children on puberty blockers progress to cross sex hormones
CR page 176
HHS page 91
VIII. Children with gender related distress frequently have other conditions, including autism, anxiety, depression, eating disorders, or a history of trauma and abuse
CR pages 90-94
HHS pages 68-69
IX. Children with gender related distress are often same-sex attracted
CR pages 118-120
HHS pages 42-48
X. NCERT controversy
In 2021, a teacher-training manual developed by NCERT proposing discussion of puberty blockers with adolescents was withdrawn following objections from the National Commission for Protection of Child Rights.
Media coverage often focused on cultural and identity issues.
Janhavi Nilekani is a public policy professional who works in maternal and child health. She is the Founder and Chairperson of Aastrika Foundation and Aastrika Midwifery Centre. She has a PhD in Public Policy from Harvard, and a Bachelor of Arts from Yale.
The views expressed in this piece are those of the author and not any institution she is affiliated with.
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