The American Academy of Pediatrics (AAP) annual convention is an opportunity for pediatricians to network, exchange ideas and learn. Unfortunately, when it comes to youth gender medicine, misinformation was on the 2024 conference agenda. As a keynote speaker, the AAP chose U.S. Department of Health and Human Services Assistant Secretary for Health Rachel Levine, the highest-ranking transgender official in the Biden administration.

Levine’s invitation should cause concern to American families who want to know that the nation’s largest pediatrician group values evidence-based medicine. Levine has supported a misinformation campaign that has turned the U.S. into an international outlier in the use of the “gender-affirming” model of care, which recommends hormones and surgeries rather than psychotherapy as the first-line treatment for adolescent distress around puberty. 

Emails recently unsealed in a lawsuit revealed that in 2022, Levine pressured the World Association for Transgender Health to remove age minimums for gender surgeries from its “standards of care.”

Since 2017, a Manhattan Institute analysis of health insurance claims has shown, that more than 5,000 teenage girls had their breasts amputated as part of a “gender-affirming” procedure designed to help them achieve a male look. This includes 50 to 179 girls who were 12-and-a-half years old or younger at the time of surgery.  

These figures represent an undercount, as they do not include procedures performed at large health care systems like Kaiser Permanente (which is currently being sued by two young women who underwent “top surgery”). Yet these surgeries do not seem to pose a problem for those like Levine who believe the theory that “trans kids know who they are.”  

Levine’s invitation ought to also be a concern to AAP members who worry that homophobia and regressive sex stereotypes are a large component of what underlies “gender affirming” treatments. Incredibly, children who do not fit sex stereotypes and same-sex attracted adolescents are now given the idea they are “trans” and encouraged to perceive hormones and surgeries as a solution to the substantial difficulties that society imposes on gender non-conforming young people. It is unwise to promote this speculative narrative, since neither data nor logic supports the concept of a “trans child.”

What we need is open, respectful, and fact-based public dialogue regarding these issues. Unfortunately, that will not occur at the AAP’s primary peer-reviewed journal, Pediatrics. This formerly high-quality journal has been used to cheerlead for the “gender-affirming care” scheme rather than to provide a forum for rigorous scholarly debate. This distortion of science conveniently helps insulate the AAP from criticism and is a prime example of how ideological activism, even if well-meaning, destroys trust in medicine.   

Until recently, these large numbers of gender dysphoric teens would have been unheard of. I was in medicine for two decades without encountering a single trans-identified youth. Youth with other types of body-related distress were common, but only in the last decade did any substantial number claim they had been born in the wrong body and request hormones and surgeries to become their “authentic selves.”

What has occurred to cause young people so much distress with their biological sex? How did they come to believe so strongly in irreversible treatments with scant supporting evidence? 

Rather being humble and accurate about what we know and don’t know regarding how to approach these young people, those within AAP have condemned anyone who advocates for a cautious, evidence-based approach as “anti-trans.” They even attempted to have their conference moved out of Florida due to erroneous and self-aggrandizing perception that “hate” is why so many across the world recommend against these treatments.

Levine’s invitation to be keynote was not the only dubious milestone for the AAP this year. The AAP also promised to conduct a systematic review of the evidence for so-called “gender-affirming care” over 13 months ago. There is no indication that the review has begun.

Systematic reviews, the gold standard in medical evidence analysis, are the reason a growing number of countries now classify puberty blockers and cross-sex hormones as “an experimental practice” and impose restrictions on their use. The AAP has refused to answer questions from journalists on the matter and excluded voices urging caution from its convention.

AAP is now under investigation by state attorneys general and, along with the author of its 2018 policy statement on “gender-affirming care,” is a named defendant in a lawsuit by a young woman who says she suffered irreparable harm because of the APP’s fraudulent recommendations.

In his book, “Blind Spots, When Medicine Gets It Wrong, and What It Means for Our Health,” Marty Makary reveals many examples of the harms of medical hubris and groupthink. One is the AAP’s reckless 2000 guidelines on peanut avoidance. Without supporting evidence, the AAP put its institutional credibility behind untested theories. When parents followed the AAP’s bad advice to avoid giving infants and young children peanuts, there was an increase in the number and severity of peanut allergies. The U.S. now leads the world in peanut allergies, which are almost unheard of in much of the world. 

The AAP quietly reversed this foolishness in 2017 but failed to learn from the episode. In 2018, it concocted its even more harmful and less evidence-based statement promoting gender-affirming care. The statement, written by a single physician with minimal clinical experience, has been thoroughly debunked and was rated unfit for use by a recent systematic review of guideline quality. The Cass Review, the most comprehensive review of youth gender medicine to date, found the AAP recommendations to be among the world’s worst.

Most embarrassing for AAP, in June, private emails unsealed as part of a lawsuit showed that even the discredited leadership at World Association for Transgender Health had said the AAP recommendations have “a very weak methodology, [and were] written by [a] few friends who think the same.” 

As a psychiatrist, I have seen firsthand how “gender-affirming” treatment approaches cause harm to vulnerable youth. Gender-affirming care is well-intended activism posing as medical treatment. It has torn families apart and eroded public trust in our medical system.

Contrary to the slogans, these treatments are not lifesaving. The AAP’s decision to invite Levine as keynote speaker and its continued lack of transparency regarding the evidence for its recommendations signal that the AAP continues to prioritize misguided advocacy over science.  

Kristopher Kaliebe is a psychiatrist and expert on youth gender medicine and professor in the Psychiatry Department at the University of South Florida.

Speed offence

British paediatrician Hilary Cass puts the spotlight on Australian gender clinics racing ahead of the safety data

genderclinicnews.com

A 2020 journal article, with RCH gender clinicians and University of Melbourne bioethicists among the authors, considers the case of 15-year-old male child “EF”, a hypothetical “non-binary” patient combining features of real cases.

After three years of hormone suppression EF’s bone mineral density has fallen to the lowest 2.5 percentile, “although there have been no fractures,” the authors say.

“EF, whose desire for biological children in the future remains unclear, wishes to continue puberty suppression until they are at least 18 years old [thereby keeping a seemingly androgynous body]. Their clinicians contact the clinical ethics consultation team to ask, ‘Is that appropriate?’”

The paper assumes, contrary to systematic reviews of the evidence, that blockers can be counted on to ease the distress of gender dysphoria and confer mental health benefits. In other words, the paper does not accept that the use of blockers with dysphoria is experimental.

Three of the Melbourne authors suggest the “attractive” option of maintaining EF on blockers while making experimental use of another medication. They say that “selective estrogen receptor modulators” (SERMs) might “theoretically promote improved bone density” without growing undesired breast tissue. It is “attractive”, they suggest, despite this new medication’s side effects including hot flashes, blood clots and possibly cognitive impairment.

Another 2020 paper involving authors from the RCH clinic and the University of Melbourne contemplates the composite case of “Phoenix”, a non-binary adult requesting ongoing puberty suppression (OPS) to permanently prevent the development of secondary sex characteristics, as a way of affirming their gender identity.”

The hypothetical Phoenix is an 18-year-old girl who has mostly identified as non-binary and began hormone suppression at age 11 after she became “extremely distressed” by the appearance of breast buds and the thought of approaching menarche.

The authors declare perpetual puberty blockers “ethically justifiable”, because the possible harms would be outweighed by benefits such as “a physical appearance that better matches gender identity.”

“We have also contended that Phoenix’s request can be regarded as substantially autonomous. Arguably, medicine is moving beyond its traditional, narrow goal of promoting health, biostatistically conceived.”

Under the rubric of more ethical work to be done with non-binary adults, the authors ask, “Should a diagnosis of gender dysphoria be required for an individual to be eligible for puberty suppression?”

Key findings of the Cass report: stop giving drugs to children and rushing them into treatment

Recommendations also include early help for pupils who wish to socially transition

The Telegraph

Children who think they are transgender should not be rushed into treatment they may regret, a landmark report has concluded.

The report by paediatric consultant Dr Hilary Cass has made 32 recommendations, including: calling for the “unhurried” care of those under 25 who think they may be transgender; an end to the prescribing of powerful hormone drugs to under-18s; and early help for primary school children who want to socially transition.

The Telegraph has summarised the report’s key findings:

Last month, the NHS banned the prescribing of puberty blockers outside of clinical trials. However, Dr Cass has gone further and said children who think they are transgender should not be given any hormone drugs at all until at least 18.

The former president of the Royal College of Paediatrics and Child Health said there was no evidence the drugs “buy time to think” or “reduce suicide risk”.

While the drugs can suppress puberty, research commissioned by the review and carried out by the University of York found the drugs have no effect on the person’s body satisfaction or their experience of gender dysphoria – where the person feels they are a different gender to the sex they were born – despite this being the reason they had been prescribed.

Dr Cass stated there was “concern that [puberty blockers] may change the trajectory of psychosexual and gender identity development” with most patients going on to take cross-sex hormones as a result.

She said the NHS should exert “extreme caution” in giving out cross-sex hormones to under-18s as the research carried out by her review concludes there is “a lack of high-quality research” on their effectiveness. She said their use should be incorporated into the puberty blocker trial.

Dr Cass said all children and teenagers should be given time “to keep options open during this development window” and that this would allow time to diagnose and treat other conditions while preserving fertility.

She said doctors must be able to “refer to the longer-term benefits and risks” of treatment options but this was “not currently available” for children experiencing gender incongruence or dysphoria. A systematic review by the University of York of more than 1,000 children who had been treated by the Tavistock, found that 7.4 per cent of under-16s given puberty blockers stopped their treatment.

It found that the younger children started treatment, the more likely they were to continue on to cross-sex hormones, which means the drugs “are not buying time to think”.

It had also been suggested that the drugs could improve body image and psychological wellbeing – however, the review found “no changes in gender dysphoria or body satisfaction were demonstrated.”

Families should be able to see a medical professional such as a child psychologist or paediatrician as quickly as possible if a primary school child wants to socially transition, the report recommends.

Dr Cass states that while “exploration is a normal process” in teenagers, children who are yet to go through puberty will have been affected by “parental attitudes and beliefs”.

She states the importance of “avoiding premature decisions” and seeking help early on to understand the child’s behaviour and assess whether they are experiencing any mental health issues or distress.

Research conducted for the review found that prepubescent children who socially transition – which means a child being treated as their preferred gender, including using their chosen pronouns and name, and allowing them to use the facilities such as lavatories and changing rooms of their choice – were more likely to undergo medical treatment later.

She suggests that a “partial rather than full transition can be a way of ensuring flexibility and keeping options open until the developmental trajectory becomes clearer”.

“There should be a distinction for the approach taken to pre- and post-pubertal children,” she said. “This is of particular importance in relation to social transition, which may not be thought of as an intervention or treatment because it is something that generally happens at home, online or in school and not within health services.”

The report finds that “social transition in childhood may change the trajectory of gender identity development for children with early gender incongruence”.

The younger children are when they present with “gender incongruence” the more likely they are to move on from that phase, it says.

“The current evidence base suggests that children who present with gender incongruence at a young age are most likely to desist before puberty, although for a small number the incongruence will persist.”

It recommends a clinical professional such as a mental health specialist “should help families to recognise normal developmental variation in gender role behaviour and expression”.

Dr Cass said her review heard concerns from many parents about their child being socially transitioned and affirmed in their expressed gender without parental involvement.

Such cases often involved an adolescent who had “come out” at school while expressing concern about how their parents might react. “Some parents felt ‘forced’ to affirm their child’s assumed identity or risk being painted as transphobic and/or unsupportive,” the report said.

In a small number of cases, there were concerns that parents were “consciously or unconsciously” influencing their child’s gender expression, it said.

“It is very important that the child/young person’s voice is heard and that perceptions of gender identity represent the child/young person’s sense of self,” it said.

Under-25s should not be rushed into changing gender, but should receive “unhurried, holistic, therapeutic support”, Dr Cass concluded. She said “life-changing” decisions must be properly considered in adulthood, noting that brain maturation continues into the mid-20s.

The report found that “clinicians are unable to determine with any certainty which children and young people will go on to have an enduring trans identity”. Young adults aged 17 to 25 who want to change gender should be seen by “a follow-through service” rather than sent straight to an adult clinic, the report concludes.

The NHS has been accused of fast-tracking thousands of teenagers to adult clinics, because they would not be seen before their 17th birthday, and prescribing them cross-sex hormones.

Dr Cass said these people were still at a “vulnerable stage in their journey” and that regional centres offering gender services for children, as well as mental health assessments and support, should care for those aged up to 25 or link up with such services.

The consultant paediatrician said it was not possible to “know the ‘sweet spot’ when someone becomes settled in their sense of self” but that decisions should not be rushed before an individual becomes a mature adult at about 25.

“When making life-changing decisions, what is the correct balance between keeping options as flexible and open as possible as you move into adulthood, and responding to how you feel right now?” she wrote in the report’s foreword.

The report said far more consideration should be given to reaching a point of maturity before taking a decision.

“It used to be thought that brain maturation finished in adolescence, but it is now understood that this remodelling continues into the mid-20s as different parts become more interconnected and specialised,” the report notes.

“Changes in the limbic area, which is ‘present-orientated’ and concerned with risk taking and sensation seeking, begin with puberty; this part of the brain becomes super sensitised, drives emotional volatility, pleasure and novelty seeking, and also makes adolescents more sensitive to social rejection, as well as vulnerable to addiction and a range of mental health problems,” the review continues.

“The ‘future orientated’ prefrontal cortex matures later, with development continuing into an individual’s 20s, and … is concerned with executive functions such as complex decision making, rational judgement, inhibition of impulsivity, planning and prioritisation,” it states.

Childhood trauma, neglect and abuse feature heavily in the cohort of patients seeking gender changes, the report shows.

It cites a systematic review that found that in some services, as many as two thirds of those referred had suffered some kind of neglect or abuse, with high levels of parental mental illness, substance abuse and exposure to domestic violence. The research found about half of cases had suffered from maternal mental illness or substance abuse while almost 40 per cent had experienced paternal mental illness or substance abuse.

An early study of UK cases referred to gender services found one quarter of children had spent some time in care. More than four in 10 cases had experienced living with only one parent, with almost as many having experience of family mental health problems.

The report shows that rates of mental ill-health have risen among children and young people, especially girls and young women.

This comes in parallel with the rising numbers seeking help from NHS gender clinics, where the biggest rise has been among those registered as female at birth, seeking help in adolescence to change gender.

Within this group, there are higher levels of neurodiversity and mental health issues, it says, calling for a “holistic” appraisal of the young patient, not solely in terms of their gender-related distress.

“Children/young people referred to NHS gender services must receive a holistic assessment of their needs to inform an individualised care plan. This should include screening for neurodevelopmental conditions, including autism spectrum disorder, and a mental health assessment,” it states.

The report advises children expressing a desire to change gender are given time to think before being rushed into a decision they may regret.

It suggests that too many decisions about changing gender have been rushed, with too little consideration given that children might regret their actions in later life.

A survey included in the findings found “the history of the child/young person’s gender journey was rarely examined closely for signs of difficulty, regret or wishes to alter any aspect of their gender trajectory.”

Evidence considered by the Cass review included talking to those who have transitioned to the opposite sex and those who have detransitioned back. It found that “whilst some young people may feel an urgency to transition, young adults looking back at their younger selves would often advise slowing down”.

It continued: “For some, the best outcome will be transition, whereas others may resolve their distress in other ways. Some may transition and then de/retransition and/or experience regret. The NHS needs to care for all those seeking support.”

Data on the number of adults who have detransitioned are scarce, but the report said the number was “increasing”. A 2021 study found that 70 per cent of people detransitioning had another condition in the first place, while 23 per cent were actually gay, lesbian or bisexual.

Shine a light

Australia's Senator Claire Chandler calls for an inquiry into gender clinics

genderclinicnews.substack.com

In September 2019, after The Australian newspaper began subjecting gender clinics to scrutiny, doctors launched an online petition for a parliamentary inquiry as requested by professor of paediatrics Dr. John Whitehall. They collected 260 names in three and a half days before a spam attack by activists forced closure of the petition. The signatories included 20 professors or associate professors, 14 paediatricians, 20 psychiatrists (nine of them child psychiatrists), and “many other doctors with a shared concern about the epidemic of childhood gender dysphoria and the lack of scientific basis for its current treatment”, organisers said.

claimed that the Health Chief Executives Forum has not responded to its request for an update on the promised progress towards a national approach to gender clinics acknowledged that its 2020 advice to Mr. Hunt “did not comment on specific clinical issues such as the use of puberty blockers and other treatments” conceded that much has happened in the field of gender dysphoria in Australia and internationally but says it has no plans to update the advice it gave to Mr. Hunt stated that it does not intend to develop clinical guidelines or position statements on the treatment of gender dysphoria

“whether children are being rushed into gender reassignment treatment” “whether psychiatrists such as Dr. Jillian Spencer … who question the use of puberty blockers without an appropriate mental health assessment are being silenced” “whether Australia should follow the United Kingdom and many European countries in adopting a more cautious approach to the prescription of puberty blocking drugs, amid concerns the evidence base for their efficacy is lacking” “whether the Commonwealth should take a greater oversight and regulatory role in the prescription of puberty blockers and cross-sex hormones to children following the admission from the federal government that it has no idea how widely the drugs are being prescribed off-label for gender dysphoria”

• https://journals.lww.com/prsgo/fulltext/2021/11000/letter_to_the_editor__regret_after.29.aspx

• https://academic.oup.com/jcem/article-abstract/107/9/e3937/6572526?login=false
• https://www.sciencedirect.com/science/article/abs/pii/S1054139X22007194
• https://www.mdpi.com/2227-9032/10/1/121

• https://link.springer.com/article/10.1007/s10508-021-02163-w
• https://www.bmj.com/content/380/bmj.p382

• https://www.bmj.com/content/380/bmj.p382
• https://www.reuters.com/investigates/special-report/usa-transyouth-outcomes/
• https://link.springer.com/article/10.1007/s11930-023-00358-x
• https://www.tandfonline.com/doi/full/10.1080/0092623X.2022.2150346

Opinion | The Endocrine Society’s Dangerous Transgender Politicization

Members we spoke with take exception to the group’s guidelines on ‘gender-affirming care.’

WSJ

A federal court last week struck down an Arkansas law banning the provision of sex-change procedures—off-label “puberty blockers,” opposite-sex hormones and surgery—to minors. In the June 20 ruling, Judge James M. Moody Jr. repeatedly cited the Endocrine Society, the professional organization of physicians who specialize in hormones. He wrote that the society has “published widely-accepted clinical practice guidelines for the treatment of gender dysphoria” that “were developed by experts in the field” and “are recognized as best practices.”

In truth, over the past decade transgender activists have co-opted the Endocrine Society and other professional organizations to promote such treatments for adolescents and even young children. Their guidelines are based on flimsy evidence, giving the appearance that invasive and irreversible treatments are beneficial for young patients despite a growing body of evidence to the contrary. The guidelines have been used by lawmakers in states such as California and New York to endanger children—and now by judges to block state efforts at protecting youngsters.

A few days before Judge Moody’s ruling, we attended the annual meeting of the Endocrine Society, of which one of us (Dr. Eappen) is a member. We found that endocrinologists are aware of the society’s failings and rue its elevation of transgender activism over medical expertise and patient needs.

The Endocrine Society endorsed medical “transition” for young people in 2017. It published the “clinical practice guidelines” for the “treatment of gender-dysphoric/gender-incongruent persons” that Judge Moody cited. At the time, there was little good research on this issue, and the Endocrine Society admitted the guidelines were largely based on evidence of “low” or “very low” quality. The society nonetheless recommended that some children receive a “hormone regimen that will suppress the body’s sex hormone secretion, determined at birth and manifested at puberty.”

At this year’s meeting, we had frank and fruitful discussions with endocrinologists who provide hormonal treatments to kids with gender dysphoria, as well as some who don’t. Without exception, they acknowledged that the society’s evidence base for pediatric gender transition is weak, at best. Yet while they’re aware of the guidelines’ shortcomings, they’re afraid to voice their concerns. The society’s full-throated endorsement of gender-affirming care implied condemnation of anyone who holds differing views. Medical professionals are being cowed into silence and coerced into providing treatments they know are dangerous to children.

Perhaps the most telling interactions were with European endocrinologists, who were there to discuss the latest research and treatments in the specialty. Those we spoke with expressed surprise that the U.S. hasn’t banned, or at least severely restricted, such treatments for adolescents and children.

England, Sweden and Finland have all taken this path, and Norway is likely to follow. Belgium, France, Ireland and Italy are also raising concerns. These countries are following the science, which shows that the claimed benefits of hormonal intervention for young people fail to outweigh the risks.

Most disturbing, endocrinologists on all sides of this debate told us that practitioners aren’t complying with the precautions set forth in the society’s guidelines. Despite the document’s call for careful mental-health screening and its acknowledgment that most cases of childhood gender dysphoria naturally resolve during puberty, endocrinologists recognize that some of their peers are rushing young patients to irreversible hormonal treatments. Every endocrinologist we spoke with supports doing more to ensure that these guardrails are enforced, and many favor erecting new ones.

Judge Moody’s ruling cites the Endocrine Society’s guidelines in a lengthy section titled “Findings of Fact,” which is essentially a recitation of transgender ideology. A trial judge’s findings of fact are all but unreviewable on appeal. By allowing ideologues to hijack their organization, endocrinologists are making themselves complicit in a scientifically baseless movement that inflicts serious harm on children’s physical and mental health.

Dr. Eappen is a practicing endocrinologist in Montreal and a senior fellow at Do No Harm. Mr. Kingsbury is Do No Harm’s research director.

Opinion | The Weak Evidence Behind ‘Gender-Affirming Care’ for Children

The Endocrine Society is ignoring the dangers that sex-change treatments pose to minors.

WSJ

Stephen Hammes’s response (Letters, July 5) to our op-ed (“The Endocrine Society’s Dangerous Transgender Politicization,” June 29) proves our point: The Endocrine Society is ignoring the dangers that sex-change treatments pose to children.

Dr. Hammes, president of the Endocrine Society, leaves out that the society’s pro-sex-change guidelines are based on “low” or “very low” quality evidence. He says nothing about the growing number of progressive European countries that are abandoning America’s model of gender-affirming care following systematic reviews of the evidence.

Dr. Hammes says that “2,000 studies published since 1975” support gender-affirming care. Yet many of these studies show negative results or nonresults, while all suffer from methodological problems like selection bias or a lack of proper control groups. These failings make it impossible to say whether drugs and surgeries were superior to less invasive alternatives like psychotherapy or even placebos. All but two dozen studies involved adults who transitioned as adults, not children, meaning more than 1,900 of the studies Dr. Hammes cites have no bearing on this issue. The layman may be impressed by the large number, but evidence-based medicine is concerned with the quality and reliability of research, not its quantity.

If Dr. Hammes is so confident in the Endocrine Society’s guidelines, he should have no problem launching a systematic review of all risks and benefits of hormonal interventions. It is more than warranted, six years after the guidelines were released. Until then, states have no choice but to pass laws to protect children from well-intended but harmful practices.

Roy Eappen, M.D., and Ian Kingsbury, Ph.D. Do No Harm Montreal and Marblehead, Mass.

Why Europe and America are going in opposite directions on youth transgender medicine

Europeans are following principles of evidence-based medicine, while Americans are not.  

The Hill

A growing number of countries, including some of the most progressive in Europe, are rejecting the U.S. “gender-affirming” model of care for transgender-identified youth. These countries have adopted a far more restrictive and cautious approach, one that prioritizes psychotherapy and reserves hormonal interventions for extreme cases.  

In stark contrast to groups like the American Academy of Pediatrics (AAP), which urges clinicians to “affirm” their patient’s identity irrespective of circumstance and regards alternatives to an affirm-early/affirm-only approach “conversion therapy,” European health authorities are recommending exploratory therapy to discern why teens are rejecting their bodies and whether less invasive treatments may help.  

If implemented in American clinics, the European approach would effectively deny puberty blockers and cross-sex hormones to most adolescents who are receiving these drugs today. Unlike in the U.S., in Europe surgeries are generally off the table before adulthood.  

Why are more countries turning their backs on what American medical associations, most Democrats and the American Civil Liberties Union call “medically necessary” and “life-saving” care? The answer is that Europeans are following principles of evidence-based medicine (EBM), while Americans are not.

A bedrock principle of EBM is that medical recommendations should be grounded in the best available research. EBM recognizes a hierarchy of information. The expert opinion of doctors, for example, even when based on extensive clinical experience, furnishes the lowest quality — meaning, least reliable — information. Slightly higher on the information pyramid are observational studies. Systematic reviews of evidence, meanwhile, furnish the highest quality evidence. They follow a rigorously developed, reproducible methodology. They do not cherry-pick studies with convenient results, but instead consider all the available research.  

Most importantly, systematic reviews don’t merely summarize the conclusions of available studies on a question of interest. Instead, they assess the strengths and weaknesses of these studies to determine the reliability of their findings. To do this, systematic reviews typically use the GRADE system (Grading of Recommendations, Assessment, Development and Evaluations) and rank the quality of evidence as “high,” “moderate,” “low” or “very low.”  

Systematic reviews by EBM experts in Scandinavia and the United Kingdom have concluded that there are serious gaps in the evidence base for sex modification in minors. The U.K. systematic reviews found the available research to be of “very low” quality — meaning that there is very low certainty that an observed effect, like reduced suicidality, is due to the intervention, and therefore the studies’ claimed results are unlikely to represent the truth.  

Importantly, even the famous Dutch study that is said to be the “gold standard” of research in this area received a rating of “very low” due to serious methodological problems. Sweden’s National Board of Health and Welfare has said that the risks of treating gender dysphoric minors with hormonal interventions “currently outweigh the possible benefits.”  

Last year, Florida’s health authorities commissioned what is known as an “umbrella review,” or a systematic overview of systematic reviews, from independent experts at McMaster University, home of EBM. Unsurprisingly, that overview came to the same conclusion: There is no reliable evidence that youth transition improves mental health outcomes.  

Because U.S. medical groups don’t always use EBM, their conclusions can be based on studies whose fatal flaws are overlooked or ignored. Consider, as an example, a study done at Seattle Children’s Hospital and published last year. The study’s authors reported that use of puberty blockers and cross-sex hormones was associated with 60 percent lower odds of depression and 73 percent lower odds of suicidality. Leading mainstream publications, including Scientific American and Psychology Today, celebrated the findings. More recently, major U.S. medical associations cited the study in federal court proceedings.  

But a careful look at the study’s data shows that the kids who received hormonal interventions did no better by the end of the study than at the beginning. The researchers’ claim about improvement was based on the fact that the kids in the control group, who received psychotherapy but not hormones, got worse relative to the hormone group. But even this isn’t accurate, as 80 percent of the control group dropped out by the end of the study, and a likely reason for this dramatic loss to follow-up is that many or perhaps all of the non-hormone-treated kids improved without “gender-affirming” drugs. It’s quite possible that if the researchers had followed up with all the participants, we’d see this study become Exhibit A in the case against pediatric sex changes.

Similar problems exist in studies purporting to show a rate of transition regret of less than 1 percent. The true rate of regret is not known and won’t be known for years to come. The claim that gender dysphoric teens are at high risk of suicide if not given access to “gender-affirming” drugs and surgeries is likewise baseless and irresponsible. In February, Finland’s top expert in gender medicine emphasized this point to the country’s liberal newspaper of record.

The American Academy of Pediatrics’ main statement on gender medicine, authored by a single doctor while still in his residency, is not a systematic review. The author himself has conceded as much. A later published peer-reviewed fact check found the AAP statement to be a textbook example of cherry-picking and mischaracterization of evidence.

The World Professional Association of Transgender Health (WPATH) says in its latest “standards of care” that a systematic review of evidence is “not possible.” Instead, WPATH used a “narrative review,” which has a high risk of bias according to EBM because it doesn’t utilize a reproducible methodology. England has broken from WPATH, and the director of Belgium’s Center for Evidence-Based Medicine has said he would “toss them [WPATH’s guidelines] in the bin.” In the U.S., WPATH’s standards are widely accepted as authoritative.

The U.S. Endocrine Society has relied on two systematic reviews in developing its own guideline. But these reviews were not for mental health benefits, and in any case the Endocrine Society ranks the quality of evidence behind its own recommendations as “low” or “very low.”

All other U.S. medical groups cite these three sources when assuring the public about “gender-affirming care,” thus creating an illusion of consensus around “settled science.”  

Earlier this year, an investigative report in the prestigious British Medical Journal concluded that although pediatric gender medicine in the U.S. is “consensus-based,” it is not “evidence-based.” Gordon Guyatt, distinguished professor in the Department of Health Research Methods, Evidence, and Impact at McMaster University, Ontario, and one of the founders of EBM, recently called American guidelines for managing youth gender dysphoria “untrustworthy.” 

Consensus can be produced by misguided empathy, ideological capture or political pressures. Consensus can also be manufactured. The new president of the American Medical Association (AMA) has said there should be “no debate” when it comes to offering kids “gender-affirming” drugs and surgeries.  

Yale School of Medicine’s Dr. Meredithe McNamara calls the questioning of the evidence behind pediatric sex changes “science denialism.” Her protest is ironic. Science is a process of ongoing inquiry and debate, not a set of predetermined conclusions. Science depends on skepticism, especially about sensitive subjects. True science denialism means restricting rational, evidence-based debate — exactly what McNamara and the AMA’s new president want to do.

Their calls are bearing fruit. Just this month, gender activists successfully pressured a medical journal to retract a paper whose conclusions they found inconvenient. The ongoing campaign to suppress scientific debate allows a pseudo-consensus to emerge around “gender-affirming care.”

Put simply, pediatric gender medicine in the U.S. is out of control. Medicalization of gender diversity in children is a fast-growing industry that shows no signs of self-correction. Doctors and therapists who practice “affirmative” medicine consistently demonstrate ignorance about EBM principles and deceive the public about the grim realities behind the euphemism “gender-affirming care.”  

A Reuters investigation last year interviewed providers at 18 pediatric gender clinics and found that none were doing comprehensive mental health assessments and differential diagnosis. Those who promote and practice “gender-affirming care” themselves tell us that their approach is child-led. “Gatekeeping” of medical transition, they insist, is pointless, even “dehumanizing.”

The author of the AAP’s position paper on gender medicine has said that a “child’s sense of reality” is the “navigational beacon to orient treatment around.” The director of the gender clinic at Boston Children’s Hospital has admitted that they give out puberty blockers “like candy.” Even the founding psychologist of that clinic has warned that kids are being inappropriately “rushed toward the medical model.”

Why the U.S. has become an outlier on pediatric transgender medicine is a complicated question, but at least part of the answer is that European welfare states have centralized health bureaucracies and public health insurance. Before medicines can be approved for state funding, their evidence base needs to be evaluated. The American health care system is more vulnerable to profit motives, activist doctors and political pressures. Medical associations claim to advocate for patient health but can have other motives as well.

The situation is so dire that when pediatric gender medicine experts in other countries want to defend their practices before a skeptical public, they sometimes say that at least they are not as bad as the Americans. That is one kind of American exceptionalism we can do without.

[A] “child’s sense of reality” is the “navigational beacon to orient treatment around.”

NHS will not offer puberty blockers to children suffering from gender dysphoria

Guidance 'will go down in safeguarding history' as hormone-suppressing drugs will not be routinely recommended at two new clinics in England

The Telegraph

Puberty blockers will not be routinely offered to children suffering from gender dysphoria, the NHS has said. Clinicians and psychologists said the decision “will go down in history” in the safeguarding of children. Guidance for two new regional gender clinics opening in England confirmed that the hormone-suppressing drugs would not be “routinely offered”. The clinics will replace the controversial Tavistock gender clinic, which is closing after a damning independent review from Dr Hilary Cass deemed it “not safe”. The Gender Identity Development Service (Gids), based at the Tavistock and Portman NHS Foundation Trust, London, was expected to close in spring this year, but it is still running. The reason for the delay is unknown. A southern hub will open this autumn, but a northern hub is not expected to open until April 2024. The Tavistock does not prescribe puberty blockers for children, but it can refer them for such drugs. Clinical research only On Friday, NHS England published an update following its previously stated intention to only commission puberty-suppressing hormones as part of clinical research. It read: “We are... proposing that, outside of a research setting, puberty-suppressing hormones should not be routinely commissioned for children and adolescents who have gender incongruence/dysphoria.” A spokesman confirmed that children treated at the new gender clinics would not be routinely offered puberty blockers as part of their treatment, but there may be exceptional circumstances in which a clinician could make a case for a child to have them. ‘Seismic’ decision An independent review, led by Dr Cass, was commissioned in September 2020 amid a rise in demand, long waiting times for assessments, and “significant external scrutiny” around the London-based Gids clinic’s approach and capacity. In 2021, the Court of Appeal ruled that children will be allowed to take puberty blockers without parental consent. The NHS said it aimed to start a study by next year on the impact of puberty blockers on gender dysphoria in children and young people with early-onset gender dysphoria. James Esses, co-founder of Thoughtful Therapists, which is focused on safeguarding children, said: “The fact that the NHS is holding firm on their intention to prevent the use of puberty blockers outside of the context of clinical trials is seismic. “This will hopefully bring an end to vulnerable children being placed down a pathway to irreversible harm.” ‘Puberty blockers don’t help’ David Bell, a former governor turned whistleblower from Tavistock said: “All the evidence shows that puberty blockers don’t help, and there is clear evidence of physical and psychological harm caused by them, so this change is in line with the evidence we have. “A very large percentage of children being treated for gender dysphoria have other problems such as autism and depression, and many are upset or confused about their sexuality.” An NHS spokesman said: “The NHS is today publishing an interim specification for gender services for children and young people, in line with advice and recommendations from the Independent Cass Review. This will allow the new centres to finalise their preparation for service provision later this year. “The NHS is now engaging on the proposal that puberty blockers will not be made routinely available outside of research. We will develop a study into the impact of puberty blockers on gender dysphoria in children and young people with early-onset gender dysphoria, which aims to be up and running in 2024.”

The evidence to support medicalised gender transitions in adolescents is worryingly weak

The effectiveness and side-effects of the most common treatments are not well understood

The Economist

Prisha Mosley was 17 when she was first given testosterone in a clinic in North Carolina, after she had declared to her parents that she was a boy. She had struggled through her teen years with anorexia and depression after a sexual assault. Luka Hein had both breasts removed as a 16-year-old in Nebraska. Chloe Cole, in California, was a year younger when she had her double mastectomy. She had been on testosterone and puberty-blocking drugs since 13, also after a sexual assault.

All three girls were experiencing “gender dysphoria”, a feeling of intense discomfort with their own sexed bodies. Once a rare diagnosis, it has exploded over the past decade. In England and Wales the number of teenagers seeking treatment at the Gender Identity Development Service (gids), the main clinic treating dysphoria, has risen 17-fold since 2011-12 (see chart 1). An analysis by Reuters, a news agency, based on data from Komodo, a health-technology firm, estimated that more than 42,000 American children and teenagers were diagnosed in 2021—three times the count in 2017. Other rich countries, from Australia to Sweden, have also experienced rapid increases.

As the caseload has grown, so has a method of treatment, pioneered in the Netherlands, now known as “gender-affirming care”. It involves acknowledging patients’ feelings about a mismatch between their body and their sense of self and, after a psychological assessment, offering some of them a combination of puberty-blocking drugs, opposite-sex hormones and sometimes surgery to try to ease their discomfort. Komodo’s data suggest around 5,000 teenagers were prescribed puberty-blockers or cross-sex hormones in America in 2021, double the number in 2017.

Dysphoria furoria

The treatment is controversial. In many countries, but in America most of all, it has become yet another front in the culture wars. Many on the left caricature critics of gender-affirming care as callously disregarding extreme distress and even suicides among adolescents with gender dysphoria in their determination to “erase” trans people. Zealots on the right, meanwhile, accuse doctors of being so hell-bent on promoting gender transitions that they “groom” vulnerable teenagers—a term usually applied to paedophiles. In October supporters and critics of gender-affirming care held rival, rowdy protests outside a meeting of the American Academy of Paediatrics. Several American states, such as Florida and Utah, have passed laws banning gender-affirming care in children. Joe Biden, America’s president, has described such laws as “close to sinful”.

Almost all America’s medical authorities support gender-affirming care. But those in Britain, Finland, France, Norway and Sweden, while supporting talking therapy as a first step, have misgivings about the pharmacological and surgical elements of the treatment. A Finnish review, published in 2020, concluded that gender reassignment in children is “experimental” and that treatment should seldom proceed beyond talking therapy. Swedish authorities found that the risks of physical interventions “currently outweigh the possible benefits” and should only be offered in “exceptional cases”. In Britain a review led by Hilary Cass, a paediatrician, found that gender-affirming care had developed without “some of the normal quality controls that are typically applied when new or innovative treatments are introduced”. In 2022 France’s National Academy of Medicine advised doctors to proceed with drugs and surgery only with “great medical caution” and “the greatest reserve”.

There is no question that many children and parents are desperate to get help with gender dysphoria. Some consider the physical elements of gender-affirming care to have been life-saving treatments. But the fact that some patients are harmed is not in doubt either. Ms Mosley, Ms Hein and Ms Cole are all “detransitioners”: they have changed their minds and no longer wish to be seen as male. All three bitterly regret the irreversible effects of their treatment and are angry at doctors who, they say, rushed them into it. Ms Cole considers herself to have been “butchered by institutions we all thought we could trust”.

The transitioning of teenagers has its roots in a treatment protocol developed in the Netherlands in the 1980s and 1990s. It is built on three pillars: puberty-blockers (formally known as gnrh antagonists), cross-sex hormones and surgery. The goal was to alter the patient’s body to more closely match their sense of cross-sex identity, and thereby relieve their mental anguish. A pair of papers published in 2011 and 2014 by Annelou de Vries, one of the Dutch protocol’s pioneers, reported on the experiences of some of the first patients. They concluded that symptoms of depression decreased among patients taking puberty-blockers, and that gender dysphoria “resolved” and psychological functioning “steadily improved” after cross-sex hormones and surgery.

Transition ignition

Puberty-blockers do what their name suggests. The idea is that suspending unwanted sexual development can give patients time to think about their dysphoria, and whether or not they wish to pursue more drastic interventions. The same family of drugs is used to treat “central precocious puberty”, in which puberty begins very early. Some countries also use them to chemically castrate sex offenders. As with many other medicines used in children, the use of puberty-blockers in gender medicine is “off-label”, meaning that they do not have regulatory approval for that purpose.

Patients who decide to proceed with their transition are then prescribed cross-sex hormones. Males will see the development of breasts and alterations to how fat is stored on the body. Giving testosterone to females boosts muscle growth and causes irreversible changes such as deepening the voice, altering the bone structure of the face and the growth of facial hair.

Under the original Dutch protocol, surgery was permitted only after a patient turned 18, although as the cases of Ms Cole and Ms Hein show, in some places mastectomies occur at a younger age. Male patients can have artificial breasts implanted. More elaborate procedures, in which females have a simulated penis built from a tube of skin harvested from the forearm or the thigh, or males have an artificial vagina made in a “penile inversion”, are performed extremely rarely on minors.

In 2020 the National Institute for Health and Care Excellence (nice), a British body which reviews the scientific underpinnings of medical treatments, looked at the case for puberty-blockers and cross-sex hormones. The academic evidence it found was weak, discouraging and in some cases contradictory. The studies suggest puberty-blockers had little impact on patients. Cross-sex hormones may improve mental health, but the certainty of that finding was low, and nice warned of the unknown risks of lasting side-effects.

For both classes of drug, nice assessed the quality of the papers it analysed as “very low”, its poorest rating. Some studies reported results but made no effort to analyse them for statistical significance. Cross-sex hormones are a lifelong treatment, yet follow-up was short, ranging from one to six years. Most studies followed only a single set of patients, who were given the drugs, instead of comparing them with another set who were not. Without such a “control group”, researchers cannot tell whether anything that happened to the patients in the studies was down to the drugs, to other treatments the patients might be receiving (such as counselling or antidepressants), or to some other, unrelated third factor.

The upshot is that it is hard to know whether any of the supposed effects reported in the studies, whether positive or negative, are actually real. Reviews in Finland and Sweden came to similar conclusions. As the Swedish one put it, “The scientific base is not sufficient to assess…puberty-inhibiting or gender-opposite hormone treatment” in children.

Two American professional bodies, the Endocrine Society (es) and the World Professional Association for Transgender Health (wpath) have also reviewed the science underpinning adolescent transitions. But es’s review did not set out to look at whether gender-affirming care helped resolve gender dysphoria or improve mental health by any measure. It focused instead on side-effects, for which it found only weak evidence. This omission, says Gordon Guyatt of McMaster University, makes the review “fundamentally flawed”. wpath, for its part, did look at the psychological effects of blockers and hormones. It found scant, low-quality evidence. Despite these findings, both groups continue to recommend physical treatments for gender dysphoria, and insist that their reviews and the resulting guidelines are sound.

One justification for puberty-blockers is that they “buy time” for children to decide whether to proceed with cross-sex hormones or not. But the data available so far from clinics suggest that almost all decide to go ahead. A Dutch paper published in October concluded that 98% of adolescents prescribed blockers decide to proceed to cross-sex hormones. Similarly high numbers have been reported elsewhere.

The reassuring interpretation is that blockers are being prescribed very precisely, given only to those whose dysphoria is deep-rooted and unlikely to ease. The troubling one is that puberty-blockers lock at least some children in to further treatment. “Time to Think”, a new book about gids by a British journalist, Hannah Barnes, cites British medical workers concerned by the latter possibility. They say patients received blockers after cursory and shallow examinations.

The Dutch researchers weigh both explanations. “It is likely that most people starting [puberty-blockers] experience sustained gender dysphoria,” they write. But, “One cannot exclude the possibility that starting [puberty-blockers] in itself makes adolescents more likely to continue medical transition.”

Perhaps the biggest question is how many of those given drugs and surgery eventually change their minds and “detransition”, having reconciled themselves with their biological sex. Those who do often face fresh anguish as they come to terms with permanent and visible alterations to their bodies.

Once again, good data are scarce. One problem is that those who abandon a transition are likely to stop talking to their doctors, and so disappear from the figures. The estimates that do exist vary by an order of magnitude or more. Some studies have reported detransition rates as low as 1%. But three papers published in 2021 and 2022, which looked at patients in Britain and in America’s armed forces, found that between 7% and 30% of them stopped treatment within a few years.

The original Dutch studies published in 2011 and 2014 were longitudinal—that is, they followed the same group of patients throughout their treatment. Yet three recent critiques published in the Journal of Sex & Marital Therapy nonetheless find fault with the studies’ data.

One of the new studies’ concerns is the small size of the original samples. The 2011 paper looked at 70 patients. But the outcome of treatment was only known for between 32 and 55 of them (the exact number depends on the specific measure). And even then, the final assessment of outcomes occurred around 18 months after surgery—a very short timeframe for a treatment whose effects will last a lifetime. (The first patient, “FG”, was followed for longer. In 2011, when in his mid-30s, researchers reported his feelings of “shame about his genital appearance” and of “inadequacy in sexual matters”. A decade later though, things had improved, and FG had a steady girlfriend.)

The critiques also suggest that the finding that gender dysphoria improved with treatment may have been an artefact of how the participants were assessed. Before treatment, female patients were asked to agree or disagree with such statements as, “Every time someone treats me like a girl I feel hurt.” This established their desire to be seen as male. After blockers, hormones and surgery the same individuals were asked questions on a scale originally developed for those born male. It offered statements such as, “Every time someone treats me like a boy I feel hurt.” Naturally, patients who preferred to be seen as male disagreed. In effect, the yardstick was changed in a way that might be seen as making positive outcomes more likely.

Finally, the original studies seem to have inadvertently cherry-picked patients for whom the treatment was most effective. The researchers started with 111 adolescents, but excluded those whose treatment with puberty-blockers did not progress well. Of the remaining 70, others were omitted from the final findings because they did not return questionnaires, or explicitly refused to do so, or dropped out of care or, in one case, died of complications from genital surgery. The data may therefore exclude precisely those patients who were harmed by or dissatisfied with their treatment.

In a rebuttal published in the same journal, Dr de Vries insists that the original papers found a significant improvement in gender dysphoria, the condition the protocol was designed to treat. She concedes that the switching of assessment scales is “not ideal” but says this does not imply the studies’ results were “’falsely’ measured”. In response to worries about the relatively short follow-up, she noted that a study reporting longer-term outcomes is due “in the upcoming years”.

What is more, whatever the merits of the Dutch team’s original research, the patients passing through modern clinics are strikingly different from those assessed in their papers. Twenty years ago the majority of patients were pre-pubescent boys; in recent years teenage girls have come to dominate (see chart 2). The findings of older research may not apply to today’s patients.

The Dutch team’s approach was deliberately conservative. Patients had to have suffered from gender dysphoria since before puberty. Many of today’s patients say they began to suffer from dysphoria as teenagers. The Dutch protocol excludes those with mental-health problems from receiving treatment. But 70% or more of the young people seeking treatment suffer from mental-health problems, according to three recent papers looking at patients in America, Australia and Finland.

Despite the protocol’s caution, says Will Malone of the Society for Evidence-Based Gender Medicine, an international group of concerned clinicians, the reality is often the reverse, especially in America, with mental-health issues becoming a reason to proceed with transitions, rather than to stop them. “We are now told that if we don’t address young people’s mental-health problems caused by dysphoria with transition, they will kill themselves.”

Gender agenda

The original Dutch protocol emphasises the need for careful screening and assessments, as do official guidelines in most countries. But whatever the guidance, there are persistent allegations that it is not being followed in practice. “I had one 15-minute appointment before I was given testosterone,” says Ms Mosley. Many American patients contacted by The Economist reported similarly brief examinations.

The possibility that many teenagers presenting as trans could instead be gay has long been discussed. The Dutch study of 2011 found that 97% of the participants were attracted either to their own sex or to both sexes. In 2019 a group of doctors who resigned from gids told the Times, a British newspaper, of their worries about homophobia in some patients and parents. They worried that, by turning children into simulacra of the opposite sex, the clinic was, in effect, providing a new type of “conversion therapy” for gay children.

Both within America and without, whatever the loudmouths may claim, the vast majority of practitioners are simply trying to ease the genuine suffering of adolescents afflicted by gender dysphoria. But in America in particular the charged atmosphere has made it very difficult to separate the science from the politics.

European medical systems have not concluded that it is always wrong for an adolescent to transition. They are not trying to erase distressed patients. They have simply determined that more research and data are needed before physical treatments for gender dysphoria can become routine. Further research could, conceivably, lead to guidelines similar to those already in use by American medical bodies. But that is another way of saying that it is impossible to justify the current recommendations about gender-affirming care based on the existing data.