Treatment for Pediatric Gender Dysphoria Review of Evidence and Best Practices

News

From U.S. Department of Health and Human Services, 5-1-25

Given the interest and controversy locally in Nassau County, statewide and nationally in so-called “gender” issues, we thought it prudent to forward you this latest HHS report. This should provide grist for some interesting discussions.

READ Treatment for Pediatric Gender Dysphoria Review of Evidence and Best Practices

We found many other takes on the situation online.

Here’s the report table of contents:

TABLE OF CONTENTS
FOREWORD 9
EXECUTIVE SUMMARY 12
Part I: Background 12
Part II: Evidence Review 13
Part III: Clinical Realities 14
Part IV: Ethical Considerations 15
Part V: Psychotherapy 16

PART I: BACKGROUND 17
CHAPTER 1 INTRODUCTION 18
1.1 Exceptionalism 21
1.2 Evidence 22
1.2.1 Evidence-based medicine 24
1.2.2 History lessons 25
1.3 Ethics 26

CHAPTER 2 TERMINOLOGY IN PEDIATRIC GENDER MEDICINE 29
2.1 Terminology in pediatric gender medicine 29
2.2 Terminology in this Review 37

CHAPTER 3 HISTORY AND EVOLUTION OF ADULT AND PEDIATRIC GENDER
MEDICINE 40
3.1 The Transsexual Phenomenon 40
3.2 From George to Christine 42
3.3 “Dear Dr. Hamburger” 44
3.4 Outcomes of adult transitions 46
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3.5 The rationale for youth gender transition 49
3.6 The spread of the Dutch Protocol and the rise of “gender-affirming care” 51

CHAPTER 4 INTERNATIONAL RETREAT FROM THE “GENDER-AFFIRMING”
MODEL 57
4.1 The rise of the affirmative care model 57
4.2 The international practice reversals 62
4.2.1 The Cass Review and its reception 64
4.3 Rationale for international reversals 65
4.3.1 Changes in the patient population 66
4.3.1.1 Epidemiological shifts 66
4.3.1.2 Mental illness and neurodevelopmental diagnoses 66
4.3.1.3 Nonbinary identities 68
4.3.1.4 Social influence 68
4.3.2 Unclear natural history and prognostic uncertainty 69
4.3.2.1 New evidence about the natural history of gender dysphoria 70
4.3.2.2 Concerns about identity development 70
4.3.3 Concerns about treatment-associated risks and harms 72
4.3.4 More appropriate understanding of suicide 73
4.3.5 Collapse of clinical rationale 75
4.3.6 Lack of reliable evidence of benefit 76

PART II: EVIDENCE REVIEW 78
CHAPTER 5 OVERVIEW OF SYSTEMATIC REVIEWS 79
5.1 Methodology 79
5.2 Outcomes of social transition 86
5.3 Outcomes of puberty blockers 86
5.4 Outcomes of cross-sex hormones 88
5.5 Outcomes of surgery 89
5.6 Outcomes of psychotherapy 90
5.7 Discussion 91
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5.7.1 Findings of this overview 91
5.7.2 Sources of uncertainty in evidence 92
5.7.3 Robustness of this overview’s conclusion 93
5.7.4 Limitations and strengths of this overview 95
5.7.5 Conclusion 96
CHAPTER 6 LIMITATIONS OF SYSTEMATIC REVIEWS 97
6.1 Insufficient elapsed time 98
6.2 Short-term observational studies 99
6.2.1 de Vries et al., 2011, 2014 100
6.2.2 Tordoff et al., 2023 101
6.2.3 Chen et al., 2023 103
6.3 Publication bias 105
6.4 Summary 107
CHAPTER 7 EVIDENCE FROM BASIC SCIENCE AND PHYSIOLOGY 109
7.1 Puberty 109
7.1.1 Overview of normal pubertal development 110
7.1.2 Tanner Stages of puberty 110
7.1.3 Neuroendocrine regulation of puberty 111
7.2 Puberty blockers and central precocious puberty 111
7.3 Puberty blockers and gender dysphoria 112
7.3.1 Developmental risks of blocking normal puberty 113
7.3.2 Bone mineral density and skeletal development 113
7.3.3 Neurocognitive and psychosocial development 114
7.3.4 Reproductive maturation 115
7.3.5 Risks of sexual dysfunction 117
7.4 Cross-sex hormones and gender dysphoria 118
7.4.1 Physical effects of cross-sex hormones 118
7.4.2 Dosing of cross-sex hormones 119
7.4.3 Hyperandrogenism in females 119
7.4.4 Hyperestrogenemia in males 119
7.4.5 Effects of testosterone on the female reproductive system 120
7.4.6 Effects of estrogen on the male reproductive system 121
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7.4.7 Cardiovascular and metabolic risks 121
7.4.8 Other risks associated with cross-sex hormones 122
7.5 Surgery and gender dysphoria 123
7.5.1 Surgical problems related to early pubertal blockade 123
7.6 Other risks associated with hormonal interventions or surgeries 124
7.6.1 Adverse psychiatric effects 124
7.6.2 Detransition and regret 125
7.7 Mortality risk 127

CHAPTER 8 SUMMARY AND IMPLICATIONS OF EVIDENCE REVIEW 129

PART III: CLINICAL REALITIES 132
CHAPTER 9 REVIEW OF INTERNATIONAL GUIDELINES 133
9.1 The role and process of clinical practice guidelines 133
9.2 Summary of systematic appraisals of clinical guidelines and guidance
documents 136
9.2.1 Methodological quality of existing guidelines and guidance documents 136
9.2.2 Interdependence of the existing guidelines and guidance documents 139
9.2.3 WPATH, Endocrine Society, and the American Academy of Pediatrics (AAP)
guidelines and practice statements 140
9.2.4 More recent international guidelines 143
9.3 Overview of recommendations in the high-quality guidelines 145
9.3.1 Finland 145
9.3.2 Sweden 146
9.3.3 United Kingdom 148
9.4 Conclusion 150

CHAPTER 10 WPATH’S STANDARDS OF CARE 8 151
10.1 Influence of WPATH in the United States 151
10.1.1 WPATH’s role in clinical practice 152
10.1.2 WPATH’s role in medical education and training 153
10.1.3 WPATH’s role in insurance reimbursement 154
10.2 The development of SOC-8 and the adolescent chapter 155
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10.2.1 Hope for evidence of effectiveness 157
10.2.2 Adolescent capacity to consent 158
10.2.3 Treatment effects 159
10.3 The process of creating SOC-8 160
10.3.1 Conflicts of interest management 161
10.3.2 Suppression of evidence 165
10.3.3 Redefinition of medical necessity 172
10.3.4 Legal and political considerations 175
10.4 Elimination of age minimums 178
10.5 Continued reliance on SOC-8 180

CHAPTER 11 COLLAPSE OF MEDICAL SAFEGUARDING 182
11.1 The Dutch Protocol and the relaxation of its criteria in the U.S. 182
11.1.1 The U.S. gender clinics’ further departure from the Dutch Protocol 183
11.2 Is pediatric medical transition “rare”? 184
11.3 Shift in objectives and the new meaning of “assessment” 186
11.3.1 Ambiguity in SOC-8 188
11.3.2 SOC-8 guardrails abandoned 190
11.3.3 Collapse of assessment times 192
11.3.3.1 Boston Children’s Hospital 192
11.3.3.2 Children’s Hospital Los Angeles 193
11.3.3.3 Lurie Children’s Hospital 193
11.3.3.4 Seattle Children’s Hospital 194
11.3.3.5 UCSF Benioff 195
11.3.3.6 Planned Parenthood 195
11.4 The whistleblowers 196
11.4.1 Laura Edwards-Leeper and Erica Anderson 197
11.4.2 Jamie Reed 198
11.4.3 Tamara Pietzke 200
11.4.4 Eithan Haim 202

CHAPTER 12 MEDICAL ASSOCIATION RESPONSE 204
12.1 The role of major medical and mental health associations 204
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12.2 Factors contributing to neglect of evidence and open debate 207
12.3 Conclusion 211
PART IV: ETHICS REVIEW 212
CHAPTER 13 ETHICAL CONSIDERATIONS 213
13.1 Consent 214
13.2 From paternalism to shared decision-making and patient-centered care 216
13.2.1 Respect for autonomy vs caveat emptor 217
13.2.2 Nonmaleficence, beneficence, and autonomy in pediatrics 219
13.2.3 Risk/benefit in pediatric medical transition 220
13.2.4 Justice 226
13.3 Alternative clinical rationales 228
13.4 Regret 234
13.4.1 Research Ethics 236
PART V: PSYCHOTHERAPY 241
CHAPTER 14 PSYCHOTHERAPY 242
14.1 Youth mental health 242
14.1.1 Trends in youth mental health 243
14.2 Diagnostic and social labels 244
14.3 Controversies regarding assessment and the role of the psychotherapist
247
14.4 Psychotherapy for GD: Re-emergence in Europe 249
14.5 Psychotherapy and its application to gender dysphoria 250
14.5.1 Psychotherapy for conditions frequently co-occurring with gender
dysphoria 251
14.5.2 Psychotherapy for gender dysphoria 254
14.5.2.1 The charge of “conversion therapy” 255
14.5.2.2 Psychotherapeutic approaches 257
LIMITATIONS, STRENGTHS, AND CONCLUSION 264
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APPENDICES 267
APPENDIX 1. ABBREVIATIONS 268
APPENDIX 2. DIAGNOSTIC CRITERIA 272
APPENDIX 3. SYSTEMATIC REVIEWS AND EVIDENCE-BASED MEDICINE 278
APPENDIX 4. OVERVIEW OF SYSTEMATIC REVIEWS: METHODOLOGY,
EVIDENCE SYNTHESIS, TABLES 288
BIBLIOGRAPHY