This morning, the Department of Health and Human Services is releasing “Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices,” a 409-page brick of a document that represents the most comprehensive guidelines ever compiled on the subject by a U.S. government agency.
The review, an advance copy of which was obtained by The Dispatch, is the result of an executive order signed by President Donald Trump on January 28 and titled “Protecting Children from Chemical and Surgical Mutilation.” As is probably evident from the language used, Trump came out swinging against youth gender treatments. “Across the country today, medical professionals are maiming and sterilizing a growing number of impressionable children under the radical and false claim that adults can change a child’s sex through a series of irreversible medical interventions,” the order began. “This dangerous trend will be a stain on our Nation’s history, and it must end.”
Trump, among other steps, directed executive branch agencies to “ensure that institutions receiving Federal research or education grants end the chemical and surgical mutilation of children” and end their reliance on “junk science” from the World Professional Association for Transgender Health, which had been considered the leading authority in this area until evidence emerged that it had succumbed to politicization and suppressed the publication of data which didn’t support transition. Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. was ordered to publish, within 90 days, a “review of the existing literature on best practices for promoting the health of children who assert gender dysphoria, rapid-onset gender dysphoria, or other identity-based confusion.”
At the time, this third mandate struck me as a bit strange: Why not conduct the review and then, if warranted, deliver the editorializing verdict about “stains on our Nation’s history”?
Alas, that is not the Trump way. And given the tone of the executive order and the extent to which this issue helped propel Trump into the White House last fall—not to mention Kennedy Jr.’s at-best-troubled relationship with sound medical science—I fully expected HHS to produce a hackish report, perhaps one authored by cranks.
But with this report, the Trump administration appears to have taken a different approach. I was shocked when I found out who was on the team of external experts commissioned by the HHS to write the report: I was familiar with almost all of them, and they were not cranks at all. They are, as expected, skeptics of rosy narratives about the efficacy of youth gender medicine, to varying degrees. But they are informed skeptics who have been deep in the weeds on these issues for a long time, and a significant number have published peer-reviewed papers on this topic.
Obtaining this document early required some negotiations, including a less-than-ideal stipulation that I would only be informed of the authors’ names off the record. For what it’s worth, Andrew G. Nixon, the director of communications for HHS, described the team as “nine experts across disciplines and political views” and explained why individual authors’ names aren’t yet being released. “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,” he said. “Names of the contributors to the review are not initially being made public, in order to help maintain the integrity of this process.”
The report is broken down into five parts: background information on the history of the controversy surrounding youth gender medicine; a review of the existing evidence; a “clinical realities” section detailing the authors’ dim view of current treatment guidelines in the United States; a chapter on the ethical considerations involved; and a final portion on psychotherapy and its role in “managing gender dysphoria in children and adolescents.”
The review accurately recounts the various twists and turns in what has become an exceedingly fraught saga in recent years, noting that multiple European countries—including Finland, Sweden, and most recently the United Kingdom via its particularly comprehensive Cass Review—have all conducted evidence reviews that reached a similar conclusion: that the outcome literature on pediatric transition is very weak, meaning we simply don’t have a sound basis to know whether these treatments should be prescribed to gender dysphoric youth. “The umbrella review found that the overall quality of evidence concerning the effects of any intervention on psychological outcomes, quality of life, regret, or long-term health, is very low,” the report concludes. “This indicates that the beneficial effects reported in the literature are likely to differ substantially from the true effects of the interventions.”
The report goes beyond merely evaluating the existing evidence. The authors argue, for example, that although the existing literature does not provide compelling evidence of meaningful benefits or harms associated with young people undergoing gender-transition treatment, “basic science” suggests there are reasons to be concerned about the latter.
Youth gender medicine involves disrupting young people’s natural puberty, exposing them to cross-sex hormones at much higher doses than their bodies would ever experience naturally, and, in some instances, removing natal females’ breasts (so-called “bottom surgeries,” in which genitalia are altered, appear to be performed on U.S. minors only in extremely rare cases)—all in the hopes of alleviating their gender dysphoria and allowing them to more easily live as their identified sex. According to the HHS team, we already know a fair amount about the potential harms of this protocol, ranging from sexual dysfunction and infertility to problems with bone health and, potentially, psychosocial development. While more and better research would be useful, the authors argue that additional studies are not fundamentally necessary to understand the myriad reasons for caution here: The harms are endemic to the very process of putting a young person through this medical protocol.
I suspect the most controversial part of the report, at least to advocates of youth transition, will be the final section on psychotherapy. The authors note that while there’s no strong evidence one way or another on the question of whether psychotherapy can alleviate gender dysphoria—in part because research into this area has been stunted by the frequent claim that anything short of medical transition is “conversion therapy”—there is strong evidence that psychotherapy can alleviate many of the symptoms often associated with gender dysphoria, like anxiety and depression. It follows, they argue, that psychotherapy should play a larger role in the treatment of youth with gender-related concerns:
Given that this population often presents with complex psychosocial histories and multiple mental health concerns, psychotherapy takes a holistic approach—addressing the full range of issues rather than focusing exclusively on [gender dysphoria]. “Transdiagnostic psychotherapy”—that is, therapy that works across or with multiple diagnoses or problems—is already a convention. While there is a clear need to develop and study therapeutic approaches tailored specifically for GD, effective therapy need not always center on a single issue. Psychotherapy for adolescents with GD is a well-suited intervention, as it is intended to help patients develop self-understanding, engage with emotional vulnerability, and build practical strategies for managing distress.
I found this section particularly compelling in part because, as the authors noted elsewhere, the recent surge in adolescents wishing to undergo gender-transition treatment is driven in large part by females without long histories of gender dysphoria who have struggled with various mental health conditions. This is now a widely acknowledged and not fully understood phenomenon, and if there were ever a situation in which clinical caution is warranted, it’s this one. When properly conducted, psychotherapy, unlike medical interventions, does not bring with it any inherent risks.
In a calmer information environment, this report could fundamentally shift the way we think and talk about youth gender medicine in the United States. But this debate is so heinously politicized that the review seems destined to be dismissed out of hand by many advocates and medical practitioners. That’s largely what happened when the Cass Review was published last year: A number of prominent youth gender medicine clinicians, activists, researchers, and other experts tarred the report by making misleading—and in some cases, outright false—claims about it. The nadir of this effort was a Yale University “Integrity Project” critique—co-authored by some prominent names in the youth gender medicine field, as well as the respected legal scholar Anne Alstott—that contained a surprising number of both errors and what appeared to be willful misunderstandings (or so I argued).
So, if we’re being realistic, there is a group of youth gender medicine advocates who are likely to reject out of hand any report produced by the Trump administration that accepts the findings from Sweden, Finland, and the United Kingdom—no matter how sober-minded. That said, the messaging surrounding the HHS review seems designed to antagonize those who will disagree with its findings rather than persuade them. By releasing such a strident executive order before conducting what actually turned out to be a careful and rigorous effort, the administration hamstrung its own ability to make inroads with those already inclined to view the review’s results skeptically.
Making matters worse, the White House released a similarly incendiary statement on Monday, previewing some of the document’s findings. “Under President Biden, the Federal government promoted a grotesque social and scientific experiment on American children,” it began. “During the first three years of his administration alone, more than 7,000 children were administered puberty blockers and cross-sex hormones. Over 4,000 were subjected to sex-trait modification surgical interventions, such as mastectomies. These interventions were marketed to children on the basis of ideologically driven and financially motivated junk-science.” The authors of the report, I was told, were not informed that their work would be framed this way.
That said, the Biden administration did, in fact, politicize this issue. Under Biden, HHS significantly overstated the evidence for youth gender medicine while almost entirely ignoring the controversy raging across Europe. Its point person on this issue, the former assistant secretary of health at HHS, Adm. Rachel Levine, also served as an advocate for these treatments. Most frustratingly, the Biden administration did not engage in the sort of careful, rigorous evidence evaluation that the Trump administration has, against all odds, published today. The Biden administration could have approached youth gender medicine in an empathetic yet appropriately skeptical manner, rather than serving as an outright cheerleader. But politics interfered.
The answer to overpoliticized science, however, is not more overpoliticized science. Thankfully, the authors of this new review seem to understand this, and have published an important document that provides open-minded readers with a clear and nuanced overview of the debate.
Too few people are willing to participate in that debate in good faith. As the report makes clear, this conversation has been dominated by overconfident advocates who have, for too long, pressured major institutions into prematurely accepting claims for the safety and efficacy of youth gender medicine. There have also been—and I say this from some personal experiences—ugly campaigns to denigrate anyone who treats this issue as the scientific controversy that it is. But the excesses of that movement have also brought out a cruelty and viciousness in some of its critics, who often seem to forget who it is they are trying to help: isolated, vulnerable children who are experiencing severe psychological distress, and parents who, by and large, are just trying to do the right thing.
“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,” the authors note. “They require, and are entitled to, accurate, evidence-based information to guide their decisions.” Today’s report is a good start, even if it is saddled by imperfect messengers at the top of the federal government.
