The health of transgender children is addressed with imprecise language and overplayed empirical evidence in new Australian guidelinesand in an Editorial (June 30, p 2576).Sex has a biological basis, whereas gender is fundamentally a social expression. Thus, sex is not assigned—chromosomal sex is determined at conception and immutable. A newborn's phenotypic sex, established in utero, merely becomes apparent after birth, with intersex being a rare exception.

1 The Royal Children's Hospital Melbourne

Australian standards of care and treatment guidelines for trans and gender diverse children and adolescents version 1.1.

Distress about gender identity must be taken seriously and support should be put in place for these children and young people, but the impacts of powerful, innovative interventions should be rigorously assessed. The evidence of medium-term benefit from hormonal treatment and puberty blockers is based on weak follow-up studies. The guidelinedoes not consider longer-term effects, including the difficult issue of detransition. Patients need high-quality research into the benefits and harms of all psychological, medical, and surgical treatments, as well as so-called wait-and-see strategies. This approach will provide reliable information for children, parents, and clinicians, and inform societal debate. We need to understand the rapid increase in referrals of girls and any relationship with gender identity legislation, the interplay between gender dysphoria, sexual orientation, and unpalatable roles in our highly-gendered society, and the twin potentials for underdiagnosis and overdiagnosis and treatment.