Despite a years-long fight to protect children in Texas, Gov. Greg Abbott and top Republican state lawmakers continue to allow medical practitioners to perform disfiguring gender operations on minors. However, the state’s top law enforcer has announced his 13-page legal opinion on the issue.

“Attorney General Ken Paxton released a formal attorney general opinion concluding that performing certain ‘sex-change’ procedures on children, and prescribing puberty-blockers to them, is ‘child abuse’ under Texas law. The holding comes at a critical time when more and more Texans are seeing the horrors that flow from the merging of medicine and misguided ideology,” the AG’s office wrote Monday.

The issue in Texas drew an international spotlight several years ago with the child abuse case of Dallas-area 9-year-old James Younger, whose mother told him he was a girl and wanted to force him—against his father’s wishes—to take sterilizing puberty blocker and cross-sex hormone drugs and eventually be castrated.

“There is no evidence that long-term mental health outcomes are improved or that rates of suicide are reduced by hormonal or surgical intervention,” Paxton wrote.

James’ case became a statewide rallying cry on the issue, with the Republican Party of Texas making it a legislative priority and more than 2 million GOP primary voters supporting a ban on the operations. However, at the state Capitol in Austin last year, top Republican lawmakers repeatedly killed the effort, and Abbott repeatedly refused to bring up the issue in the Legislature’s three special sessions.

Texas Scorecard chronicled the legislative saga as well as officials’ subsequent blame game, which involved Abbott passing the political hot potato to AG Paxton and other state agencies.

“Specifically, the opinion concludes that certain procedures done on minors such as castration, fabrication of a ‘penis’ using tissue from other body parts, fabrication of a ‘vagina’ involving the removal of male sex organs, prescription of puberty-suppressors and infertility-inducers, and the like are all ‘abuse’ under section 261.001 of the Texas Family Code,” Paxton wrote, adding that medical practitioners cannot truly alter an individual’s biological identity, only “destroy a fully functioning sex organ in order to cosmetically create the illusion of a sex change.”

“Beyond the obvious harm of permanently sterilizing a child, these procedures and treatments can cause side effects and harms beyond permanent infertility, including serious mental health effects, venous thrombosis/thromboembolism, increased risk of cardiovascular disease, weight gain, decreased libido, hypertriglyceridemia, elevated blood pressure, decreased glucose tolerance, gallbladder disease, benign pituitary prolactinoma, lowered and elevated triglycerides, increased homocysteine levels, hepatotoxicity, polycythemia, sleep apnea, insulin resistance, chronic pelvic pain, and increased cancer and stroke risk,” Paxton’s opinion read.

“There is no doubt that these procedures are ‘abuse’ under Texas law, and thus must be halted,” Paxton concluded. “The Texas Department of Family and Protective Services (DFPS) has a responsibility to act accordingly.”

Despite the AG’s opinion, the results are yet to be seen, particularly at controversial clinics such as Children’s Medical Center in Dallas. Citizens and pro-family organizations are again exhorting Gov. Abbott to reconvene the state Legislature and finally enact a law to ban the operations in Texas.