Although acres of print have been devoted to the trans issue, most people still assume that medical transition is a well-researched and reliable treatment for vulnerable individuals with gender dysphoria.
This is a stark example of how misinformation takes hold. In truth, those who have studied the field know that, in terms of long-term outcomes, medical transition for both adults and children sits somewhere between homeopathy and lobotomy.
A new Finnish study published last Saturday caused public consternation by showing unfavourable long-term outcomes for those who medically transitioned. Among adolescents who underwent medical transition, psychiatric morbidity rose sharply. Their mental health did not improve after treatment and, in fact, worsened over time. For those familiar with the evidence, the findings came as no surprise. Although helpful, it is one more study pointing in the same direction. There are now many such studies, and none reliably demonstrate a clear long-term benefit for medical transition in either adults or children.
Any apparent positive findings in the literature typically rely on short-term, self-reported measures drawn from studies that are often small, heterogeneous, and methodologically limited. These limitations are frequently carried into systematic reviews – for example, the recent Lancet paper reports improvements in quality of life and mental health, yet these outcomes are drawn largely from observational studies using subjective endpoints, with inconsistent use of control groups, variation in outcome measures across studies, and limited long-term follow-up, which constrains the strength of any conclusions about sustained, objective clinical benefit. This is a generalisation and individual studies may be cited in response, but the larger point remains – there is no robust, replicable, high-quality body of evidence demonstrating clear, objective long-term benefits of medical transition in either adults or children.
By contrast, the Finnish study is by orders of magnitude more comprehensive and methodologically rigorous than much of the literature routinely cited to support claims that paediatric gender medicine is evidence-based. It draws on national-level data, follows individuals over extended periods, and captures real-world clinical outcomes rather than relying on short-term self-report. The tendency to dismiss such large-scale, longitudinal evidence while leaning on far weaker studies reflects a field that has struggled to maintain consistent evidentiary standards.
To understand how we arrived here, it is worth tracing the history.
Medical transition began as a fringe practice, carried out by a small number of clinicians. It attracted little interest from mainstream medicine, and those involved were often personally invested, whether identifying as transgender themselves, closely connected to someone who did, or drawn to the radical nature of the work. It was not seen as a serious or promising field and was widely regarded as lacking legitimacy, so ambitious young doctors tended to steer clear of it.
These interventions were highly experimental and typically carried out in jurisdictions with looser regulations, such as Morocco. Over time, it became more acceptable, mostly through professional lobbying and small, qualitative studies based on self-report. In the 1960s, Johns Hopkins Hospital became the first American academic institution to offer gender reassignment surgery, largely driven by the now disgraced clinician, Dr John Money. Unlike earlier efforts, this clinic operated within a major hospital and conducted long-term outcome studies. In 1979, research by Meyer and Reter found no objective advantage in social functioning for those who underwent surgery compared with those who sought it but did not receive it. With no evidence of long-term benefit, the clinic closed soon after.
Following this decision, the U.S. Department of Health and Human Services determined in 1981 that medical transition would not be covered under Medicare, classifying them as experimental and lacking sufficient evidence of effectiveness. Federal insurance coverage ceased, and although private provision continued, institutional endorsement declined. This position remained in place until the ban was lifted in 2014 following a legal challenge. This change reflected a shift in how treatment was conceptualised, with less emphasis on objective long-term outcomes and greater focus on individual autonomy and the development of an “informed consent” model. Under this approach, the individual is positioned as the lead decision-maker, while clinicians act as facilitators who provide access to medical treatment.
Across this time period, however, the long-term outcomes remained the same as they ever were, consistently bleak. In 1991, Kuiper and Cohen-Kettenis reported poor outcomes in a cohort of 141 Dutch transsexuals, including a 70% loss to follow-up and 12 deaths among 105 male participants.
Loss to follow-up is a central methodological problem in this field. When the majority of participants disappear from studies, and when 76% of detransitioners report never informing their clinic, any outcome data claiming success becomes deeply questionable, particularly in a population already at elevated risk of suicide.
In 2011, Cecilia Dhejne and colleagues published a 30-year follow-up study in Sweden. Compared with matched controls, those who underwent medical transition had a suicide rate more than 19 times higher than the general population, alongside increased rates of psychiatric inpatient care, criminal involvement, and substance misuse.
Given findings such as these, why has this practice persisted? The reasons are complex, but much rests on the rising status of qualitative, self-reported outcomes within psychiatry and psychology, alongside the elevation of patient-led care and a broader tendency towards over-diagnosis and over-medicalisation. At the same time, the profession, chastened by its past treatment of lesbian, gay, and bisexual people, came to view transgender identification through a similar lens and was eager to demonstrate its newly adopted positivity.
In this context, patient self-report was elevated. If a patient declared satisfaction with their transition, the treatment was deemed a success – hence the comparisons with lobotomy and homeopathy. The studies that supported medical transition were often small, short-term and difficult to replicate, frequently involving participants with significant psychiatric comorbidities. Medical transition remained a fringe area, and the lack of replicable studies was largely overlooked as practitioners continued to enthusiastically affirm patient self-reports, while the public paid little attention because the numbers were tiny. Many people swear by their transition, just as others swear by Reiki or detox diets as effective treatments, but subjective reports are not a substitute for objective outcomes.
This all changed when the focus shifted to children. Public attention sharpened, arguably because the trans medical industry overreached and began medicalising gender nonconforming children. Over a ten-year period, there was a 4000% rise in adolescent females seeking medical transition at the Gender Identity Development Services (GIDS) at the Tavistock and Portman in London. GIDS treated Irish children; the youngest recorded Irish patient to receive puberty blockers was 9, and the youngest Irish patient was a 5 year old.
Parents have been central in challenging medical transition as a treatment. As one parent put it, “It’s all fine until it happens to your kid.” But if doctors are going to suggest irreversible and life-changing medical treatment, they should watch out: mothers and fathers will follow this treatment with an eagle eye.
The vast majority of the children offered paediatric medical transition are neurodiverse or same-sex attracted. They are often highly suggestible and searching for identity. Parents report moving from confusion to concern, to intensive research, and finally to anger as they encounter a body of evidence that is sloppy, reliant on self-report, difficult to replicate, and based on small samples with significant psychiatric comorbidities, yet forms the foundation of this medical intervention.
It is important to note that every drug used in paediatric transition is prescribed off-label. No pharmaceutical company has developed or tested puberty blockers or cross-sex hormones for the treatment of gender dysphoria in minors (or “gender incongruence” as it is now called in this world of ever-changing goalposts). There are no clinical trials supporting their use in this context. Doctors may prescribe them, but not on the basis of evidence for this indication.
When the available evidence for the treatment of children was systematically reviewed, the conclusions were weak. In 2020, the National Institute for Health and Care Excellence conducted two such reviews, one on puberty blockers and one on cross-sex hormones. Both found no clear clinical benefit on key outcomes and rated the quality of evidence as “very low certainty”.
Following concerns raised by parents about GIDS, the eminent paediatrician, Dr Hilary Cass, and a team of researchers spent four years examining the evidence for the treatment of minors and concluded in the Cass Review that the evidence base is weak and uncertain, and that clinical practice has moved ahead despite known and potential risks. The GIDS clinic at the Tavistock has since been closed.
Extraordinary claims require extraordinary evidence, as Carl Sagan put it. It is not enough for a small number of individuals to report positive experiences. Medical transition carries significant risks, including infertility, sexual impairment, urinary incontinence, osteoporosis, cardiovascular complications, early-onset dementia, and chronic pain. To offer this as a medical treatment approach, it must be supported by robust, replicable evidence demonstrating clear and reliable benefit before it can be considered acceptable healthcare.
When people like me first realised that medical transition, in both children and adults, was unsupported by quality evidence, we were shocked. It was difficult enough to inform the public that it was inappropriate for minors, but how were we to explain the issue with adults? Most organisations responded by focusing on children. As a result, the public wrongly assumed that adult medical transition was supported by evidence.
At Genspect, the organisation I founded in 2021, we widened the focus to include both children and vulnerable adults. We don’t believe in bans for adults, prohibition seldom works. Instead we are focused on removing medical transition from the banner of healthcare. This is not healthcare. It should not be performed by doctors in hospitals. If people wish to pursue extreme body modification, they are free to do so, but it should not be funded by the public purse or provided in hospitals.
There is a strong case for those diagnosed with differences of sexual development (DSDs, also known as intersex conditions) to receive medical care for their conditions, but not for those seeking to appear more masculine, feminine or nonbinary. This belongs within the remit of cosmetic surgery.
Every quality long-term study in this field that measured objective outcomes such as employment, psychiatric comorbidities, suicidality, and criminality demonstrates that medical transition offers poor outcomes. If you have been diagnosed with gender dysphoria and want the best change of long-term wellbeing, consider psychosocial supports such as psychotherapy. You don’t need to medicalise. You can wear dresses, paint your nails, and learn to accept your body.
Medical transition might offer short-term reward. The idea of changing your body to match your mind is very compelling, and the increased libido, strength and energy for females who take testosterone is very satisfying, but over time, when measured objectively, the trajectory of medical transition is likely to be one of long-term harm.
Stella O’Malley (PhD) is a psychotherapist and founder-director of Genspect. Her doctoral research focused on gender dysphoria in children and adolescents