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By Moti Gorin and Kathleen McDeavitt
Contributors, HHS’ "Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices"
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The Department of Health and Human Services (HHS) recently published Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices. Given current widespread distrust of HHS, especially regarding vaccines, we knew this review, which we co-authored, would be met with skepticism. So, it is worth noting that we, along with most of the other authors, are liberals.
While everyone should be concerned when vulnerable populations do not receive appropriate medical care, those of us on the left side of the political spectrum need to pay special attention. This is because many of the organizations and individuals we trust have gotten this issue wrong.
Let’s start with a bit of medical history.
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The approach to pediatric gender distress currently favored in the U.S., which involves the provision of puberty blockers and cross-sex hormones sometimes followed by surgery, was rapidly adopted internationally largely on the basis of a Dutch experiment comprised of just 70 adolescents who had been gender nonconforming since early childhood. The vast majority of these patients (62 out of 70) reported being exclusively same-sex attracted (gay).
During the study, a patient died of surgical complications due to having been given puberty blockers years earlier; some developed diabetes and were excluded from final data analysis; others were lost to follow up. The remaining 55 patients underwent surgical transition upon reaching legal adulthood. All were rendered sterile. In short, the medical practice now known euphemistically as pediatric "gender affirming care" is based on methodologically weak research that sterilized a group of gay or bisexual youth and left one of them dead.
Since then, thousands of well-meaning parents have been led to believe that medicalization is necessary for their children’s well-being. What they may not know is that some leading clinician-researchers have buried unfavorable research and have minimized concerning findings (including completed suicides in minors started on hormones).
In 2021, a prominent clinician told the media and other clinicians that her male patients who were puberty-blocked early never developed the ability to experience sexual pleasure. A year later, her organization, the World Professional Association for Transgender Health, released guidelines that recommend early use of puberty blockers (and which removed age limits—even for most surgeries—due to political pressure). The risk of lifelong sexual dysfunction was left unmentioned.
This should be concerning to anyone who cares about protecting vulnerable populations. As the HHS review observes, “Given the medical profession’s history of pathologizing and medicalizing same-sex attraction, serious justice-related concerns are raised by the overrepresentation of gay, lesbian, and bisexual adolescents among patients receiving unproven interventions that adversely impact fertility and sexual function.”
While it may sound jarring to readers who have, reasonably, deferred to U.S. medical societies and civil rights advocacy groups on this issue, there is no longer any legitimate scientific controversy about the weak evidence underlying the purported benefits of the “gender affirming” model for youth. Readers may also be surprised to learn that the first countries to restrict these practices were politically progressive Finland and Sweden, whose socialized health care systems are widely admired. It was these Scandinavian social democracies—not U.S. red states—that were first to conduct systematic reviews and conclude there is no reliable evidence supporting pediatric medical transition. Finland sharply restricted the practice in 2020, followed by Sweden in 2022. The U.K. was next, and other nations are pulling back, too.
The HHS review’s evidence analysis arrives at the same conclusion regarding the sorry state of the evidence. Weighing the purported benefits against the risks (which include not only infertility and sexual dysfunction but also decreased bone density, delayed cognitive development and inability to breastfeed after mastectomy) the review concludes that the harms of pediatric medical transition far outweigh the unproven mental health benefits.
Instead of medicalization, minors with serious gender-related discomfort should get less risky talk therapy and social support, not to force them to be gender-conforming, but to help manage distress. Kids should be supported in their identity exploration and self-expression and supported as they navigate their social lives. For minors convinced they want permanent bodily changes, therapists can be there to help them cope with the frustration of delaying permanent interventions until they are physically and psychologically mature enough to make such decisions as adults. Research suggests that for many minors with gender-related distress, this discomfort will resolve during the course of normal adolescent development.
While recent polling shows that a majority of Democratic voters oppose pediatric medical transition, the issue remains intensely polarized among politicians and policymakers. Conservatives and liberals alike can agree that all people, and especially children, deserve ethical, evidence-based care. We recognize that liberals distrust anything coming from the current administration, but we hope they will take the time to read this review and see that it puts science first.
Moti Gorin, PhD, MBE, is a bioethicist and philosopher at Colorado State University. He was a contributor to HHS’ Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices and has published on issues at the intersection of pediatric medical transition and medical ethics.
Kathleen McDeavitt, MD, is a psychiatrist and associate professor at Baylor College of Medicine. She was a contributor to HHS’ Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices and has published on topics related to the evidence base and clinical guidelines in pediatric gender medicine.
The views expressed in this article are the writers’ own.
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