Texas Governor Greg Abbott has ordered state agencies to investigate reports of gender-dysphoric children undergoing "sex change" procedures as child abuse, in accordance with an opinion released by the state attorney general's office earlier this week.

In a letter to the Department of Family and Protective Services sent Tuesday, Abbott noted the agency is "responsible for protecting children from abuse." The governor said that under Texas law, "doctors, nurses, and teachers" are required to report instances of alleged abuse and that there are "criminal penalties" for licensed professionals who fail to do so.

“Texas law imposes reporting requirements upon all licensed professionals who have direct contact with children who may be subject to such abuse, including doctors, nurses, and teachers, and provides criminal penalties for failure to report such child abuse,” Abbott said.

His letter was copied to several other state agencies, including the Health and Human Services Commission, Texas Medical Board, and Texas Education Agency.

The Dallas News first reported Abbott's letter, which was sent one day after Texas Attorney General Ken Paxton released an opinion that determined certain medical and chemical procedures recommended for transgender people constitute illegal abuse when performed on children. The attorney general's opinion is not legally binding, but former officials told the Dallas News there is a general expectation that agency directors will follow them.

The specific "sex-change procedures" identified in Paxton's opinion include castration, surgery to remove male genitals, surgeries to remove the female reproductive system, plastic surgeries to construct artificial genitals, so-called "top surgery" to remove female breasts, or any procedure that removes a "healthy or non-diseased body part or tissue" from children when not medically necessary.

Paxton also said that providing cross-sex hormones to children including puberty blockers, unnatural doses of testosterone for females, and unnatural doses of estrogen for males potentially constitutes child abuse.

These determinations are qualified with the acknowledgement that in rare circumstances some of these procedures are medically necessary for children with a "medically verifiable genetic disorder of sex development" or who "do not have the normal sex chromosome structure for male or female" as determined by medical testing.

"This opinion does not address or apply to medically necessary procedures," Paxton said.

The effect of Abbott's order is yet to be determined. It has drawn immediate opposition from transgender advocates, and some progressive prosecutors have said they will not follow the attorney general's interpretation of the law.

“My office will not participate in these bad faith political games,” said Harris County Attorney Christian D. Menefee in a statement Tuesday. "As the lawyers handling these cases, we owe a duty of candor to the courts about what the law really says. We’ll continue to follow the laws on the books — not General Paxton’s politically motivated and legally incorrect ‘opinion.’”

The Travis District and County Attorneys also told the Dallas News they will not prosecute child abuse cases when gender dysphoric children are given so-called "gender-affirming" treatment.

“The Republican leadership of this state is trying to turn loving and supportive parents into criminals, and this office will play no part in it,” said County Attorney Delia Garza.

The office of District Attorney Jose Garza said they will likewise decline to prosecute cases based on Paxton's guidance.

State agencies have mostly remained silent since the governor sent his letter.

“We will follow Texas law as explained [by Paxton’s opinion],” said DFPS spokesman Patrick Crimmins in a statement to the Dallas News. "At this time, there are no pending investigations of child abuse involving the procedures described in that opinion.”

The guidance from Paxton and Abbott contradicts the medical advice from national medical groups including the American Medical Association, American Psychiatric Association, and American Academy of Pediatrics, which believe the best way to care for transgender children is to affirm their self-proclaimed gender identity.

The World Professional Association for Transgender Health, a group that recommends the standards of care for people experiencing gender dysphoria, says that sex-change surgeries are not recommended until a patient has reached the legal age of maturity and has lived continuously for at least a year in the gender role they identify with.

The group's standards recommend that cross-sex hormones should only be given to youth after the onset of puberty and after mental health evaluation. Children who have not reached puberty are recommended to seek mental health care to treat gender dysphoria, but care that attempts to help gender dysphoric children accept and identify with their biological sex has been likened to "conversion therapy" and is opposed by medical groups.

There are serious risks to cross-sex hormone therapies, which include decreased sexual function, increased health risks, sterility, and more.

WPATH blasted the governor's action in a statement.

“Targeting trans youth, their parents, and their health care providers for political gain is unconscionable. We strongly denounce this alarmist and misguided opinion which could obstruct access to medically necessary care,” WPATH told the Dallas News.

The LGBT advocacy group Equality Texas characterized what Abbott and Paxton have done as "campaign stunts" meant to fend off primary challengers from the right in the upcoming election on Tuesday.

“We urge all Texans to be skeptical about campaign stunts disguised as legal opinions from a corrupt politician who has no expertise in healthcare and who has built their career spreading disinformation about marginalized communities,” said Equality Texas CEO Ricardo Martinez in a statement.

On the other side, social conservative groups applauded Paxton's opinion.

"Children cannot consent to taking drugs and undergoing surgeries that can permanently sterilize them and radically alter the course of their lives. And any person who assists or encourages minors in pursuing these ends is committing child abuse, period," said Terry Schilling, president of the American Principles Project.

"APP strongly commends AG Paxton for courageously standing up for Texas’ children in the face of these attacks. And we urge other state attorneys general to follow his lead to protect the innocence of our nation’s kids from the woke ideologues and Big Pharma executives eager to exploit them,” he added.