Clementine Breen was only 14 years old when she underwent a double mastectomy. Breen was put on puberty blockers at age 12 after she expressed discomfort with her changing body and started questioning her sex.

By 13, with the help of the Center for Transyouth Health and Development at Children’s Hospital Los Angeles, she was on testosterone, chemically altering her body to resemble a boy. The mastectomy, at 14, was simply the next stop on a treatment track she’d been riding since she was barely old enough to understand what any of it meant or the lifelong complications she might face.

At 18, Breen transitioned back to her biological sex after receiving therapy for childhood sexual abuse.

But seeking care for her detransition brought scrutiny instead of support: a breast reconstruction consultation turned into repeated questioning of her psychological stability — scrutiny she did not face when requesting a mastectomy at 14 — and one of her former doctors cut off communication entirely once he learned she was transitioning back.

Breen still lives with complications from the interventions she underwent as a teenager. She has irregular, untrackable menstrual cycles, severe cramps and hormonal instability, chest pain during menstruation, and vaginal atrophy requiring topical estrogen. One OB-GYN admitted that no standard care plan exists for someone with her history.

Breen’s story is one of thousands. Children steered toward irreversible medicalization on the promise it would fix them and then left to face the damage alone.

As physicians ourselves, we cannot read Breen’s story without thinking of the oath we took at the beginning of our careers, one built on the basic principle that a doctor’s first duty is to do no harm.

That oath is meant to guide every care decision and ensure patients can trust that doctors have their best interests at heart, especially, as in Breen’s case, when the patient is too young to fully understand the decisions being made for her.

Yet physicians’ betrayal of their patients’ best interests goes beyond mere pressure and influence.

A new report published by the Department of Health and Human Services, Office of the Assistant Secretary for Health, titled “Wolves in White Coats: How Doctors and Hospitals Pushed and Profited from the Fraud of ‘Gender Medicine,’” reveals health care professionals profited off pediatric sex-rejecting procedures by setting vulnerable children on a lifelong path of medicalization.

Such a lucrative revenue stream was not confined to a handful of bad actors, however. The report documents examples from clinics in multiple states, housed within major academic medical centers, large private hospital systems — including some of the top-ranked children’s hospitals — and community clinics, many of them enrolled in Medicaid and Medicare programs that serve children.

For the doctors and institutions involved, the financial upside was substantial.

For example, a single mastectomy nets a provider more than $12,000 from insurers, and so-called “bottom surgeries” can cost well over $100,000 once staged procedures and follow-up care are factored in.

One watchdog database tracking billing for minors found nearly $120 million in charges nationwide since 2019, spanning thousands of surgeries and courses of hormones and puberty blockers.

Some institutions profited more than others. Mount Sinai Medical Center in New York and Boston Children’s Hospital were among the top-grossing providers nationwide, billing more than $8 million and $6.5 million respectively for these services to minors between 2019 and 2023.

Worse, the report presents evidence that providers secured insurance coverage for these procedures through potentially fraudulent means, systematically diagnosing minors with conditions they did not have — endocrine disorders or precocious puberty — in order to justify coverage for treatments like breast removal and hormone therapy that insurers otherwise would have denied.

The report’s own analysis of a nationwide insurance claims database shows that between 2015 and 2025, private and public insurers were billed nearly $50 million for puberty blockers prescribed to children ages nine to 17 under an endocrine disorder diagnosis, a code that a separate Manhattan Institute analysis found rose 30% among minors between 2020 and 2022.

The pattern is even starker with the diagnosis of early onset, or precocious puberty. Insurers, including Medicaid and Medicare, were billed nearly $11 million for puberty blockers prescribed to hundreds of patients between ages 13 and 17 under that diagnosis, even though, by definition, no one 13 or older can actually have precocious puberty. These findings expose the providers and institutions involved to potential civil and criminal liability.

None of this happened in a vacuum. Hours after his inauguration in 2021, President Joe Biden signed an executive order declaring it the policy of his administration to combat discrimination based on so-called “gender identity,” directing every federal agency to act accordingly.

Biden’s HHS followed within months, announcing it would treat any refusal to provide or cover sex-rejecting procedures by doctors, hospitals, or insurers as a form of illegal sex discrimination.

That pressure was echoed and reinforced by medical associations like the World Professional Association for Transgender Health and the Endocrine Society, whose guidelines, which were not grounded in scientific evidence, gave political dictate the appearance of settled science, leaving doctors who might otherwise have exercised caution at risk of professional censure.

As physicians, we entered this field believing that our first obligation was to the patient in front of us, not to the prevailing political consensus. It is long past time for our profession, and the political and academic institutions that govern it, to reckon with how badly that trust was betrayed, and to hold accountable the doctors, hospitals, and policymakers responsible.

Clementine Breen cannot get her body back. But the thousands of children still ahead of her deserve a medical system that puts their well-being above ideology, profit, and political pressure. That work starts with honesty about what happened — and it starts now.

Admiral Brian Christine is the assistant secretary for health at the Department of Health and Human Services and worked with Dr. Aaron Kheriaty on the “Wolves in White Coats” report.