A report from the U.S. Department of Health and Human Services (DHHS) examining ‘gender-affirming’ care has raised “serious concerns” about using medical treatments and surgeries to “transition children and adolescents away from their sex.”
And it warned that “the risks of pediatric medical transition include infertility/sterility, sexual dysfunction, impaired bone density accrual, adverse cognitive impacts, cardiovascular disease and metabolic disorders, psychiatric disorders, surgical complications, and regret.”
Launching the report prior to peer review, the DHSS said that its findings highlight “a growing body of evidence pointing to significant risks—including irreversible harms such as infertility—while finding very weak evidence of benefit” for medical transition for children.
They added that the weakness of evidence for benefit “has been a consistent finding of systematic reviews of evidence around the world”.
Dr Jay Bhattacharya, the director of the National Institutes of Health, said: “Our duty is to protect our nation’s children – not expose them to unproven and irreversible medical interventions.
“We must follow the gold standard of science, not activist agendas.”
The review said that the “gender-affirming” model of care, as practiced in U.S. clinics, often minimized or omitted comprehensive mental health assessments in order to have a “child-led process” – and said that, in some leading pediatric gender clinics, “assessments are conducted in a single session lasting two hours.”
The DHSS said that the review was informed by an evidence-based medicine approach, reveals serious concerns about medical interventions, such as puberty blockers, cross-sex hormones, and surgeries, that attempt to transition children and adolescents away from their sex.
The report, titled ‘Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices,” was published by the Office of the Assistant Secretary for Health and Office of Population Affairs.
Addressing the use of puberty blockers and other treatments, the report said that “despite increasing pressure to promote these drastic medical interventions for our nation’s youth, the review makes clear: the science and evidence do not support their use, and the risks cannot be ignored.”
A recent review by paediatrician Dr Hilary Cass in the UK, cautioned against the use of puberty blockers for children and adolescents, saying that “the reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress.”
However, the DHSS report went further, and was highly critical of the use of puberty blockers in that age cohort saying that even conducting a trial on same was unethical.
It said: “The likelihood of infertility when puberty blockers are provided at the early stage of puberty and followed by cross-sex hormones does not have to be demonstrated in a clinical trial. This is because the mechanism is well understood and conducting a trial would amount to an unethical ‘parachute test’.”
The report said that, “In many areas of medicine, treatments are first established as safe and effective in adults before being extended to pediatric populations. In this case, however, the opposite occurred: clinician-researchers developed the pediatric medical transition protocol in response to disappointing psychosocial outcomes in adults who underwent medical transition.”
“The protocols were adopted internationally before the publication of the first outcome studies. In recent years, in response to dramatic shifts in the number and clinical profiles of minor patients, as well as to multiple systematic reviews of evidence, health authorities in an increasing number of countries have restricted access to puberty blockers and cross-sex hormones, and, in the rare cases where they were offered, surgeries for minors. These authorities now recommend psychosocial approaches, rather than hormonal or surgical interventions, as the primary treatment.”
“There is currently no international consensus about best practices for the care of children and adolescents with gender dysphoria,” the report added.
“The risks of pediatric medical transition include infertility/sterility, sexual dysfunction, impaired bone density accrual, adverse cognitive impacts, cardiovascular disease and metabolic disorders, psychiatric disorders, surgical complications, and regret,” it also warned.
The report was scathing about the “most influential clinical guidelines for the treatment of pediatric gender dysphoria” which it said published by The World Professional Association for Transgender Health (WPATH) and the Endocrine Society.
“A recent systematic review of international guideline quality did not recommend either guideline for clinical use after determining they “lack developmental rigour and transparency”. Problems with the development of WPATH’s Standards of Care, Version 8 (SOC-8) extend beyond those identified in the systematic review of international guidelines. In the process of developing SOC-8, WPATH suppressed systematic reviews its leaders believed would undermine its favored treatment approach. SOC-8 developers also violated conflict of interest management requirements and eliminated nearly all recommended age minimums for medical and surgical interventions in response to political pressures,” the DHSS report claimed.
“Although SOC-8 relaxed the eligibility criteria for access to puberty blockers, cross-sex hormones, and surgeries, there is compelling evidence that U.S. gender clinics are not adhering even to those more permissive criteria,” it added.
“The “gender-affirming” model of care, as practiced in U.S. clinics, is characterized by a child-led process in which comprehensive mental health assessments are often minimized or omitted, and the patient’s “embodiment goals” serve as the primary guide for treatment decisions. In some of the nation’s leading pediatric gender clinics, assessments are conducted in a single session lasting two hours,” the authors added.
“Over the past decade, the number of children and adolescents who question their sex and identify as transgender or nonbinary has grown significantly. Many have been diagnosed with a condition known as “gender dysphoria” and offered a treatment approach known as “gender-affirming care.” This approach emphasizes social affirmation of a child’s self-reported identity; puberty suppressing drugs to prevent the onset of puberty; cross-sex hormones to spur the secondary sex characteristics of the opposite sex; and surgeries including mastectomy and (in rare
cases) vaginoplasty. Thousands of American children and adolescents have received these interventions,” the report said.
“While sex-role nonconformity itself is not pathological and does not require treatment, the use of pharmacological and surgical interventions as treatments for pediatric gender dysphoria has been called “medically necessary” and even “lifesaving.” Motivated by a desire to ensure their children’s health and well-being, parents of transgender-identified children and adolescents often struggle with how best to support them. Many of these children and adolescents have co-occurring psychiatric or neurodevelopmental conditions, rendering them especially vulnerable.”
“When they seek professional help, they and their families should receive compassionate, evidence-based care tailored to their specific needs. Society has a special responsibility to safeguard the well-being of children. Given that the challenges faced by these patients intersect with deeply contested issues of moral and social significance—including social identity, sex and reproduction, bodily integrity, and sex-based norms of expression and behavior—the medical practices that have recently emerged to address their needs have become a focus of significant controversy.”
“This Review is published against the backdrop of growing international concern about pediatric medical transition. Having recognized the experimental nature of these medical interventions and their potential for harm, health authorities in a number of countries have imposed restrictions. For example, the UK has banned the routine use of puberty blockers as an intervention for pediatric gender dysphoria. Health authorities have also recognized the exceptional nature of this area of medicine. That exceptionalism is due to a convergence of factors. One is that the diagnosis of gender dysphoria is based entirely on subjective self-reports and behavioral observations, without any objective physical, imaging, or laboratory markers. The diagnosis centers on attitudes, feelings, and behaviors that are known to fluctuate during adolescence,” the report said.
“Additionally, the natural history of pediatric gender dysphoria is poorly understood, though existing research suggests it will remit without intervention in most cases. Medical professionals have no way to know which patients may continue to experience gender dysphoria and which will come to terms with their bodies.”
“Nevertheless, the “gender-affirming” model of care includes irreversible endocrine and surgical interventions on minors with no physical pathology. These interventions carry risk of significant harms including infertility/sterility, sexual dysfunction, impaired bone density accrual, adverse cognitive impacts, cardiovascular disease and metabolic disorders, psychiatric disorders, surgical complications, and regret.”
“Meanwhile, systematic reviews of the evidence have revealed deep uncertainty about the purported benefits of these interventions. The controversies surrounding the medical transition of minors extend beyond scientific debate; they are deeply cultural and political. Public discourse is dominated by intensely polarizing narratives. Some view the medical transition of minors as a pressing civil rights issue, while others regard it as a profound medical failure and a sobering reminder that even modern medicine is vulnerable to serious error.”
“In the midst of this highly charged debate, children and adolescents, and their families—who seek only to support their flourishing—have found themselves caught between competing perspectives. They require, and are entitled to, accurate, evidence-based information to guide their decisions.”
WPATH STATEMENT
In January, WPATH hit out at President Trump’s executive order on children with gender dysphoria, saying “policies that restrict or ban access to necessary medical care for transgender youth are harmful to patients and their families.”
“Transgender youth need comprehensive, individualized, family-based care from multidisciplinary teams. Healthcare decisions should be made by patients, families, and their healthcare professionals, guided by evidence-based practices, clinical guidelines, and individual needs rather than government mandates,” it said.
However, the DHSS report said that “U.S. medical associations played a key role in creating a perception that there is professional consensus in support of pediatric medical transition. This apparent consensus, however, is driven primarily by a small number of specialized committees, influenced by WPATH. It is not clear that the official views of these associations are shared by the wider medical community, or even by most of their members. There is evidence that some medical and mental health associations have suppressed dissent and stifled debate about this issue among their members.”
It added that “the voices of whistleblowers and detransitioners have played a critical role in drawing public attention to the risks and harms associated with pediatric medical transition. Their concerns have been discounted, dismissed, or ignored by prominent advocates and practitioners of pediatric medical transition.”
The DHSS said that the review “fills a gap in the medical literature and existing clinical practice reviews with regard to the ethical aspects of pediatric medical transition” and that DHHS sought to make medical ethics central to the debate.
“Contributors to the review include medical doctors, medical ethicists, and a methodologist. Contributors represent a wide range of political viewpoints and were chosen for their commitment to scientific principles,” it said.
“Chapters of this review were subject to peer review prior to this publication, and a post-publication peer review will begin in the coming days involving stakeholders with different perspectives. Names of the contributors to the review are not initially being made public, in order to help maintain the integrity of this process,” it added.
JUDICIAL REVIEW OF IRISH TREATMENT
Last month, a legal action seeking a judicial review of the Irish State’s treatment of children with gender dysphoria issues was taken by Prof Donal O’Shea and psychiatrist Dr Paul Moran, who are leading experts working with the National Gender Service.
Both medics, who have been critical of gender affirming care, had made a prior formal complaint against the Health Service Executive (HSE) with Hiqa over the HSE’s referral of young people with such issues for assessment abroad, saying it posed a risk to these children.