There is not strong evidence that "gender-affirming care" for minors is effective for treating gender dysphoria or improving mental health, according to a report issued on Thursday by the Department of Health and Human Services, based on a review of existing literature.
The researchers found that existing studies suffer from bias and methodological errors, while the literature also fails to appropriately consider potential "harms" such as the loss of sexual function.
“The ‘gender-affirming’ model of care includes irreversible endocrine and surgical interventions on minors with no physical pathology,” reads the report’s foreword. “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.”
In an executive order titled "Protecting Children from Chemical and Surgical Mutilation," issued on January 28, President Trump announced that the secretary of health and human services would publish 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" within 90 days.
"Given the toxicity of this issue, and in order to allow for a peer-review process that focuses on the substance of this report, the names of the contributors are not being released at this time," a source familiar with the report told National Review.
Like the Cass Review commissioned by the U.K. National Health Service on gender-related medical care for minors that concluded "this is an area of remarkably weak evidence" in 2024, the HHS report 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. “
“Proponents of PMT often describe it as lifesaving. Some physicians recommending PMT have urged anxious parents to consent to irreversible interventions for their distressed children, warning that not doing so may increase the risk of suicide,” reads the report. “Such claims are not supported by the evidence and have been criticized as unethical.”
Additionally, the HHS report, titled “Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices,” notes a blind spot in the existing studies: Most fail to appropriately consider any potential harms.
The HHS report is an umbrella review of 17 preexisting systematic reviews, with some reviews encompassing more than one topic — two on the effects of social transition, nine on puberty-blocking drugs, eight on cross-sex hormones, three on surgery, and five on psychotherapy. The HHS researchers measured the quality of evidence as high, moderate, low, or very low by evaluating the risk of bias, unexplained variations in results, a lack of direct evidence, wide confidence intervals, small sample sizes, and other methodological errors. Of the 17 systematic reviews, seven were rated as having a "high risk of bias overall," while others similarly suffered from methodological flaws.
Although the HHS report says that the two systematic reviews on social transition in minors both had a "low risk of bias," the researchers stated that the "evidence on regret associated with social transition is extremely limited" and "the certainty of evidence for these outcomes is very low." The researchers note that there are no long-term studies on this subject with appropriate comparison groups, while the available literature often did not properly isolate social transition from other interventions for analysis.
With respect to the nine systematic reviews on puberty blockers, the researchers assessed only four as having a "low risk of bias," and there were big gaps throughout the studies, such as failing to evaluate differences in the drugs' effects on male versus female participants. Even though "puberty blockers" are sometimes branded simply as drugs that "pause" puberty, the HHS report notes that "no studies have systematically examined their role in the decision-making process or the outcomes of those who discontinue treatment." The report further states that there is limited data about the long-term effects of puberty-blocking drugs on growth, fertility, and neurocognitive development.
Of the eight systematic reviews on cross-sex hormones in minors, only half had a "low risk of bias." The studies in this area suffered from design flaws, according to the HHS researchers, and often evaluated short-term changes rather than long-term consequences like effects on fertility, cardiovascular health, and sexual dysfunction. Additionally, the outcomes, such as quality of life, were measured inconsistently.
The three systematic reviews on surgery focused mostly on mastectomies for adolescent females, and the researchers deemed two as having a "low risk of bias." The studies, according to the HHS report, often had a case-series or small observational designs without appropriate comparison groups and therefore are inadequate to analyze the effects of surgical intervention specifically.
“The certainty of evidence is very low regarding the effect of surgery on GD [gender dysphoria] or incongruence, improvement in mental health including suicidality and depression, and long-term outcomes such as sexual function, quality of life, and regret,” states the report.
Only two of the five systematic reviews on psychotherapy were assessed as having a "low risk of bias." The researchers state that it is difficult to generalize the available evidence, since psychotherapy may occur in many different forms (online, in person, one-on-one, group, family-based, at a brief retreat, in a clinic, during a residential program, etc.).
However, the researchers did not find any reported harms from psychotherapy treatment, although they note that the available literature sometimes conflates "psychotherapy" with "conversion therapy," and some studies did not isolate the effects of psychotherapy from those possibly resulting from concurrent interventions like social transition.
The HHS report dedicates a chapter to psychotherapy specifically, stating that children with gender dysphoria often present at gender-medicine clinics with co-occurring neurodevelopmental disorders and mental health conditions such as depression, anxiety, eating disorders, and suicidality, among others. The researchers cite that Sweden, Finland, and England have recently imposed restrictions on medicalized interventions for gender dysphoria, and those countries now encourage more traditional mental health approaches such as psychotherapy.
That chapter further dismisses the characterization of psychotherapy as "conversion therapy," which the report describes as "a problematic and potentially harmful rhetorical device." The section also mentions that gender-related medicine itself has similarly been branded as "conversion therapy" by critics, who argue that attempting to change someone's body in response to perceived personal and social disapproval is similar to attempting to alter someone's sexual orientation due to social pressure.
“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 GD [gender dysphoria],” states the report. “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.”
The HHS researchers identify a publication bias toward positive outcomes in the effectiveness of gender-related medical interventions, and the studies also suffer limitations for detecting harms, which results in part from short-term studies not tracking such outcomes. In some instances, design flaws prevented or discouraged a study from reporting harms, such as a 2023 study that hypothesized benefits in psychological outcomes but did not evaluate physical health outcomes.
Additionally, the report alleges that some professional bodies — such as the World Professional Association for Transgender Health — suppressed studies that would have evaluated harms. National Review previously reported that the American Academy of Pediatrics adopted new procedural rules that insulated a resolution raising concerns about gender-related medicine from review.
Furthermore, the HHS report claims that some systematic reviews arrived at positive evaluations of gender-related interventions despite the studies in question either contradicting or failing to support such an outcome.
“The absence of evidence of harms in published studies is not equivalent to evidence of absence of harms,” reads the report.
The United Kingdom's Cass Report, published in 2024, arrived at a similar conclusion: "It has been evident that there has been a failure to reliably collect even the most basic data and information in a consistent and comprehensive manner; data have often not been shared or have been unavailable."
Although the clinical studies on pediatric gender medicine provide insufficient reporting on harms, available scientific studies in other fields supply data. For example, the HHS report considers the literature on puberty suppression for reasons unrelated to gender transition (such as early-onset puberty) and finds that such interventions do see negative outcomes, such as lower body mass index. For those on cross-sex hormones, potential harms include increased risks of cancer and cardiovascular events such as heart attacks, as well as a loss of sexual function.
Given the adverse physical and psychological effects that may follow from medicalized transition, the HHS report notes that some individuals do "detransition," although the rate of which is unknown. One clinical study on children reported a 7.1 percent regret rate, and another found a 25 percent rate of discontinuing cross-sex hormones. However, two other studies found low rates of cross-sex hormone discontinuation or re-identification with sex.
In the chapter dedicated to medical ethics, the researchers evaluate the low thresholds and sometimes circular reasoning for a "gender dysphoria" diagnosis, and whether gender-related medical interventions have a favorable risk/benefit profile. The chapter argues that medical transition almost certainly does not provide health benefits proportionate to its harms: “If using hormonal and surgical interventions to reduce psychiatric morbidity associated with gender dysphoria lacks a favorable risk/benefit profile, using these interventions merely to satisfy adolescents' embodiment goals veers from clinical error into clinical recklessness.”
Although President Trump referred to so-called gender-affirming care as “chemical and surgical mutilation,” the HHS report avoids such rhetoric and instead adopts terms like “pediatric gender medicine.”
In its chapter on terminology, the report states that it rejects common phrases used in academic studies on gender-related medicine, including the euphemisms "top surgery" for mastectomies and "sex assigned at birth" for "sex." The report uses "cross-sex hormones" rather than "gender-affirming hormone therapy," and "sex reassignment surgery" as opposed to "gender confirmation surgery." Additionally, "gender-affirming care" is referred to as "pediatric medical transition."
The report is limited in scope to gender-related medicine for minors and does not evaluate the efficacy of such treatments for adults. The report does not make any policy recommendations for the regulation of gender-related medicine.
“While no clinician or medical association intends to fail their patients — particularly those who are most vulnerable — the preceding chapters demonstrate that this is precisely what has occurred,” concludes the report.
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