The HHS Report on Pediatric Gender Dysphoria - a summary (Part 1 of 4)

Where I summarize the report in parts, chapter by chapter. Part 1 today.

The other parts are here: Part 2, Part 3, Part 4

Unlike the Cass Review, which became a lightning rod throughout the world, the HHS report, “Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices,” seems to be suffering from the reverse condition—anonymity. Nobody in the mainstream media wants to talk about it, and when they do, it appears to be “whatever the HHS is saying runs counter to what American medical organizations say; and anyway, they promote the discredited notion of psychotherapy.” Mind you, this is for a report that runs into almost 600 pages (including the appendices). Reading 600 pages—or even 400 in the main document—is possibly asking for too much. In this series, therefore, I summarize the report. My intention is that if you read something about a section of the report and want to know more, this summary should lead you right to that section. And if you don’t have the time to read any of the report, at the very least, you will take away a proper idea about what it contains, rather than relying on the often very unsatisfying news reports about it.

Needless to add, this summary is not sanctioned by the HHS or anyone else. It is how I have summarized the report, and any errors that exist are mine. However, since the report is freely available, anyone can check how faithful I have been to it. [Note: I have tried to ensure that wherever I have introduced my own observations, they are within square brackets. ]

The report has five main parts:

1. Background (Chapters 1-4): This section goes over the history of gender dysphoria (GD), including what has happened in recent years. This Substack post covers this section.

2. Evidence review (Chapters 5-8): where the report goes over the many systematic reviews conducted in recent years worldwide [fun fact: the American medical organizations—whether it is the AMA, the APA, the AAP, or the Endocrine Society—are yet to publish any] and puts together all that we know. Spoiler alert: the overall quality of evidence of benefits is extremely low, while the evidence of harm is, well, less uncertain in some areas and almost conclusive in others—the review has covered this evidence.

3. Clinical realities (Chapters 9-12): A vital section that looks into the reasons behind what, till recently, was an extremely rare phenomenon, has now spawned over 100 specialized pediatric gender clinics in the United States within the last decade or so.

4. Ethical considerations (Chapter 13): a single chapter, and it covers why, given the lack of evidence of benefits and the presence of some real risks of harm, medical ethics has an outsize role to play to prevent the possibility of iatrogenic harm.

5. Psychotherapy (Chapter 14): also a single chapter [and the only section that critics of the review seem to talk about, and that too, quite misleadingly]. An unfortunate byproduct of the cultural war is that any psychotherapy in this area that does not immediately affirm a patient and prescribe medical interventions has been labeled as conversion therapy, leading to a dearth of research on psychotherapy for GD (partly due to it being mischaracterized as “conversion therapy”).

I will also note here that it is so refreshing to find that any assertions within the review—like them or hate them—are accompanied by extensive citations and, in what seems like a strange anachronism in this area of medicine, the citations actually back up the assertions.

I will begin with a summary of the foreword and the executive summary (!).

Foreword & Executive Summary

• Foreword: The foreword introduces the context of increasing numbers of youth identifying as transgender or nonbinary and receiving “gender-affirming care” (the HHS review does not favor such an ambiguous term and uses a more accurate “pediatric gender medicine” instead), which includes social affirmation, puberty blockers, cross-sex hormones (CSH), and surgeries. It notes the controversy surrounding these interventions, especially given co-occurring conditions in many youth and the irreversible nature of treatments applied to minors without physical pathology. It highlights growing international concern and restrictions (e.g., the UK banning routine puberty blockers) due to the experimental nature and potential harms (infertility, sexual dysfunction, bone density issues, etc.) compared to uncertain benefits. This section emphasizes the subjective nature of the diagnosis, the poorly understood natural history (often remitting without intervention), and the polarized public debate. It clarifies that the Review aims to provide accurate, evidence-based information for policymakers, clinicians, and families, focusing solely on pediatric care, without making any legislative recommendations.

• Executive Summary: Provides a condensed overview of the report's five parts.

1. Part I (Background): Defines gender dysphoria (GD), notes rising diagnoses, international disagreement on treatment, the concept of ROGD, the dominance of the WPATH-recommended “gender-affirming” model in the US (emphasizing medical interventions over psychotherapy), concerns about misleading terminology, the unusual trajectory of pediatric protocols preceding established adult evidence, and the recent international shift towards restricting medical interventions in favor of psychosocial approaches. It concludes there's no international consensus.

2. Part II (Evidence Review): Introduces the principles of Evidence-Based Medicine (EBM). A review of the many systematic reviews (called an “umbrella review”) found very low-quality evidence for the benefits (psychological outcomes, quality of life, regret, long-term health) of any intervention, which suggests that reported benefits likely differ substantially from true effects. Evidence for harms is sparse in reviews but likely underdetected due to short follow-up, poor tracking, and publication bias [this is always the case with harms from an intervention: it takes much longer to establish them]. Established physiological knowledge points to significant risks: infertility/sterility, sexual dysfunction, impaired bone density, adverse cognitive impacts, cardiovascular/metabolic disorders, psychiatric issues, surgical complications, and regret.

3. Part III (Clinical Realities): This section notes that influential US guidelines (WPATH, Endocrine Society) lack rigor and transparency and were not recommended for use by a systematic review. It summarizes the many flaws in WPATH SOC-8 development (suppressed reviews, conflicts of interest, political pressure leading to removal of age minimums). It shows that US clinics often don't adhere even to SOC-8's relaxed criteria, minimizing mental health assessments and prioritizing patient “embodiment goals.” It highlights the critical role and subsequent dismissal of whistleblower and detransitioner concerns. It critiques US medical associations for creating a perception of consensus driven by small, WPATH-influenced committees and suppressing dissent.

4. Part IV (Ethical Considerations): While affirming patient autonomy to refuse care, the section argues there is no right to receive non-beneficial interventions. Given uncertain benefits and less uncertain harms, providers should refuse interventions posing unnecessary risks, even if requested. It notes regret rates are unknown, and regret/satisfaction alone doesn’t determine medical justification. It raises ethical concerns about conducting high-quality research (like randomized control trials or RCTs) on these interventions due to potential conflicts with human subjects research standards.

5. Part V (Psychotherapy): This section situates the rising presentations in youth GD within the broader adolescent mental health crisis. It notes that suicidality is associated with common comorbidities (which have known psychotherapeutic treatments), not independently with GD, and that there is no evidence that medical transition reduces suicide. It points out the dearth of research on psychotherapy for GD (partly due to mischaracterization as “conversion therapy”). It highlights the evidence for psychotherapy for mental health comorbidities seen in youth suffering from GD. It presents psychotherapy as a noninvasive alternative with no evidence of adverse effects in this context.

PART I: BACKGROUND

Chapter 1: Introduction

• This chapter sets the stage by noting the significant increase in US adolescents identifying as transgender or questioning their gender, with many receiving hormonal or surgical treatments. It defines Gender Dysphoria (GD) as distress related to one's sexed body/social expectations. It introduces “gender-affirming care” as the dominant US approach (following WPATH/Endocrine Society guidelines), involving social transition, puberty blockers (PBs), cross-sex hormones (CSH), and surgeries, often starting at young ages (PBs at Tanner Stage 2).

• It emphasizes the review's necessity due to the controversial nature of these irreversible interventions, the lack of international consensus (contrasting US versus European approaches), and the suffering of youth and families. It clarifies that GD is distinct from nonconformity to sex-role stereotypes, which is not pathological.

• The chapter outlines the review’s scope: covering the history (Dutch Protocol), current practices, international retreat from the affirmative model, the exceptional nature of pediatric gender medicine (PGM), problematic US guidelines, extreme toxicity and polarization, and the inadequate response of medical associations. It highlights the review’s reliance on Evidence-Based Medicine (EBM) and medical ethics.

• Exceptionalism (1.1): PGM is unique due to: 1) Diagnosis based solely on subjective reports/observations without objective markers; 2) Natural history suggesting resolution often occurs without intervention, with no way to predict persistence; 3) Invasive, irreversible treatments with poor quality evidence for benefits but known risks (infertility, sexual dysfunction, bone/cardiovascular issues, potential brain impact). The shifting rationales for treatment (managing GD vs. comorbidities vs. embodiment goals) add to its exceptionalism.

• Evidence (1.2): Contrasts strong endorsements of gender-affirming care by US bodies (AMA, HHS) citing reduced suicide/improved mental health, with the UK's Cass Review finding “remarkably weak evidence” and no good data on long-term outcomes. It introduces EBM as the framework for assessing efficacy, highlighting the importance of systematic reviews (SRs) and clinical trials over intuition/experience. It notes that the umbrella review confirms the weak evidence base (Chapter 5) and that basic science points to serious harm (Chapter 7). It cautions against unquestioning acceptance of medical consensus, citing historical errors (e.g., peanut allergies, ineffective common procedures) and the potential for bias (e.g., the opioid crisis).

• Ethics (1.3): Introduces medical ethics, tracing principles like “First, do no harm” (non-maleficence) and beneficence (promoting patient well-being). It emphasizes that while patient autonomy (making informed decisions) is crucial, it doesn’t override the physicians’ duty to avoid harm or provide non-beneficial care, even if requested. The section poses the central ethical question [to my mind, a question that is even more vital than the evidence of interventions]: Is pediatric medical transition consistent with these principles?

Chapter 2: Terminology in Pediatric Gender Medicine (PGM)

• This chapter argues that the language used in pediatric gender medicine (PGM) often lacks scientific grounding, presupposes ethical conclusions, and can mislead patients and families, hindering responsible discussion.

• Terminology in PGM (2.1): This section critiques some commonly used terms:

1. “Gender-affirming care,” “gender-affirming surgery,” “top surgery”: The positive connotations obscure the nature of interventions (e.g., mastectomy).

2. “People,” “folks,” “young people,” “adolescents” instead of “children”: Masks the young age at which interventions like PBs (potentially starting at 8 or 9) can occur.

3. “Retransitioning” instead of “detransitioning,” “dynamic desires”: Downplays the potential distress and challenges of detransition.

4. Avoidance of “sex,” “male,” “female,” “boy,” “girl”; use of “sex assigned at birth” (AFAB/AMAB): Critiques “assigned sex” as suggesting arbitrary choice rather than observation of a biological reality and notes its mandated use in some journals despite biological inaccuracy. It argues that this language critiques the concept of biological sex itself.

5. “Gender identity”: Contrasts the original 1960s meaning (sense of knowing one's sex) with the current vague WPATH definition (“deeply felt, internal, intrinsic sense of their own gender”). Argues the term is ill-defined and circular in SOC-8.

6. “Transgender”: Defined via the unclear “gender identity,” leading to the concept of an innate, immutable transgender identity (“trans kids” vs “cis kids”). This framing dismisses therapeutic exploration as unethical “conversion therapy.” Notes that the claim that children “know who they are” is used to determine identity simply by asking, despite the phenomenon of desistance/detransition. Using “transgender children” implies that medical intervention is the default.

• Terminology adopted in the Review (2.2): Explains the terms adopted for accuracy and neutrality, following recommendations like the UK’s RSG report:

1. Uses standard terms: “sex,” “male,” “female,” “boy,” “girl,” “mother,” etc.

2. Avoids “sex assigned at birth” as misleading.

3. Avoids “gender” where ambiguous; avoids “gender identity” as it inherits the obscurity of “gender.”

4. Avoids “transgender child” to prevent implying medicalization is the default.

5. Uses “social transition” for changes in name, pronouns, presentation.

6. Uses “Gender dysphoria (GD)” as the accepted DSM term, despite issues with “gender.”

7. Uses “Gender nonconformity” or “sex-stereotype nonconformity.”

8. Uses “Pediatric Gender Medicine (PGM)” for the field.

9. Uses “Pediatric Medical Transition (PMT)” instead of “gender-affirming care.”

10. Uses “Cross-sex hormones (CSH)” instead of “gender-affirming hormone therapy.”

11. Uses standard clinical terms for surgeries (e.g., “mastectomy”).

12. Uses “Sex reassignment surgery (SRS)” instead of “gender confirmation surgery.”

Chapter 3: History and Evolution of Adult and Pediatric Gender Medicine

• This chapter traces the history of medical transition, arguing that pediatric practices emerged paradoxically from disappointing outcomes in adults.

• The Transsexual Phenomenon (3.1): Notes historical examples of gender nonconformity and “third genders” but distinguishes them from modern transsexualism. Mentions Havelock Ellis's “eonism” and David Cauldwell’s coining of “transsexual” (1949). Highlights Harry Benjamin's influential 1966 book “The Transsexual Phenomenon,” which popularized CSH and SRS to help “miserable” individuals become “happier” members of the “opposite sex.” Notes early rarity, citing Einar Wegener/Lili Elbe's early, fatal surgeries (1930-31).

• From George to Christine (3.2): Details the sensational 1952 case of George Jorgensen becoming Christine Jorgensen via surgery in Denmark, which catapulted transsexualism into public awareness. Describes Jorgensen's background (femininity, conflicted homosexuality, belief in a “glandular imbalance”) and connection with Benjamin. Mentions Christian Hamburger, the Danish endocrinologist who treated Jorgensen, possibly motivated by compassion for homosexuals like his sister. Notes the procedures (estrogen, castration, penectomy, attempted vaginoplasty) and Jorgensen’s subsequent 30-year celebrity before dying at 62.

• “Dear Dr. Hamburger” (3.3): Discusses Hamburger’s 1953 analysis of 756 letters from 465 people received after Jorgensen’s case became public. It notes that correspondents were mainly male, some teenagers, seeking a sex change. Highlights the finding that nearly all female correspondents and most male correspondents reported same-sex attraction. Quotes a 16-year-old girl wanting to be a boy, partly due to being in love with a girl. Links childhood gender nonconformity to later homosexuality, citing the DSM-5-TR. Notes Benjamin’s framing of male transsexual attraction to men as “natural,” given their female “psychological status.” Shows the phenomenon was still nascent (Benjamin saw only ~300 cases by 1965, mostly male). Notes the formation of HBIGDA (later WPATH) in 1979 and its first Standards of Care emphasizing medical justification, not elective procedures. Cites low prevalence estimates from DSM-III (1980) and DSM-IV (1994).

• Outcomes of adult transitions (3.4): Focuses on the Netherlands, where national health insurance covered transitions from the 1970s. Details a key 1988 study by Peggy Cohen-Kettenis and Bram Kuiper of 141 Dutch transsexuals (mostly male-to-female, MF). While subjective happiness and “passing” ability were generally reported as good post-transition, objective measures were poor: high rates of post-treatment suicide attempts (especially MFs), high unemployment, and lack of romantic partners. Notes that the study found no correlation between happiness and stage of transition, speculating that this might be due to the anticipation of future surgeries. The study acknowledged that SRS was “no panacea” and that it could create new problems. This section also discusses possible reasons MFs fared worse (difficulty passing, societal view, later transition age, burden of past life), while noting the study overlooked factors like relationship preservation for FMs and the appeal of transition for those facing homophobia. Finally, it mentions the Dhejne et al. (2011) Swedish study confirming higher long-term risks (mortality, suicide, psychiatric morbidity) post-SRS compared to the general population.

• The rationale for youth gender transition (3.5): Explains how Cohen-Kettenis, observing poor adult outcomes, theorized that earlier transition (before adulthood) would improve quality of life by enhancing “passing” and reducing the “burden of a past life.” Describes early cases in the mid-1990s where she referred patients aged 16-17 for hormones. Details the first use of puberty blockers (PBs) in 1987 by Dutch endocrinologist Henriette Delemarre-van de Waal on “FG,” a 13-year-old girl with early-onset GD and same-sex attraction, who later reported mixed outcomes (no regret but depression, sexual inadequacy). Recounts Cohen-Kettenis's collaboration with Delemarre-van de Waal, leading to the “Dutch Protocol”: PBs from age 12 (Tanner Stage 2), CSH at 16, surgery at 18, for carefully selected youth (early-onset GD worsening at puberty, mentally healthy, family support).

• The spread of the Dutch Protocol and the rise of “gender-affirming care” (3.6): Notes that the formerly HBIGDA endorsed PBs in SOC-6 (2001) based only on the FG case study, erroneously calling them “fully reversible.” Describes the adoption of PBs in the US (Boston Children's, ~2007) and UK (GIDS, 2011), often without minimum age limits. Highlights the shift from the strict Dutch criteria to a more patient-led “gender-affirming” model, treating patients with adolescent onset, comorbidities, and neurodiversity. Notes HBIGDA became WPATH (2007), and SOC-7 (2012) marked a departure towards affirmation, removing age limits for CSH and minimizing psychotherapy/real-life experience requirements. Mentions the shift in SOC-7’s title from “Gender Identity Disorders” to include “Transgender and Gender Nonconforming People.” Cites the two Dutch follow-up studies (2011, 2014) as foundational evidence, despite later revelations of flaws (see Chapter 4 below). Notes that the cohort was almost entirely same-sex attracted. Describes the subsequent surge in referrals, especially adolescent females (Figure 3.1), the rise of ROGD, the long waitlists in Europe, and the proliferation of US clinics. Concludes with the emerging international concerns and reversals (e.g., Cass Review) leading away from the PMT model.

Chapter 4: International Retreat from the “Gender-Affirming“ Model

• This chapter details the rapid expansion of the “gender-affirming” model based on the Dutch Protocol and the subsequent global trend towards restricting this approach for minors due to accumulating concerns.

• The rise of the affirmative care model (4.1): Describes how PBs and CSH were incorporated into Endocrine Society (2009) and WPATH (2012) guidelines before the final Dutch outcome study (2014) or systematic reviews (SRs) were published. Notes the concurrent surge in referrals, particularly adolescent females (Figure 4.1), contrasting with earlier cohorts of mostly prepubertal boys. Identifies the two Dutch studies (de Vries 2011, 2014) as the main scientific justification, despite significant methodological flaws (retrospective selection bias, reduced sample size in follow-up, limited clinical relevance of reported improvements, failure to account for high baseline functioning, inadequate reporting of harms like death and diabetes). Highlights that attempts to replicate findings in the UK and US were unsuccessful or yielded unfavorable results, with publication delays. Notes that the expansion was fueled by the belief in the Dutch Protocol's success, leading to increased demand and proliferation of clinics, especially in the US. Mentions that Finland first raised concerns about changing demographics and potential harms, leading to the first national guideline revision restricting medical interventions based on an SR.

• The international practice reversals (4.2): Details the growing scrutiny and policy reversals starting around 2020. Highlights the influential UK Cass Review (published April 2024), which led to the closure of the GIDS clinic, a ban on routine PBs outside trials, and significant restrictions on CSH (with no minors found eligible since). Lists other countries restricting PMT: Finland (2020, the first to revise guidelines), Sweden (2022, restricting hormones to research/exceptional cases), Denmark (2023), Norway (advising PBs/CSH are experimental), [a side note: the healthcare systems in all these countries are ranked very high—much higher than the US—Finland is ranked no. 1, followed by Sweden, Norway, and Denmark at nos. 6, 7, and 10] and recent restrictions in Brazil, Chile, Alberta (Canada), and Queensland (Australia). Notes ongoing reviews or guideline development in Australia, Italy, France (where endorsement of PMT is anticipated despite criticism), Germany (where their new guidelines face controversy), and the Netherlands itself (reviewing the Dutch Protocol).

• The Cass Review and its reception (4.2.1): Clarifies that the Cass Review was an independent service evaluation, not a CPG (clinical practice guideline), prompted by concerns about care quality and safety. The criticisms often misunderstand its purpose and stem largely from US-based advocates and contain factual errors. There is a wide acceptance of the Cass Review in the UK by major parties and the NHS as foundational for realigning PGM with EBM and child safeguarding.

• Rationale for international reversals (4.3): Explains that the shift away from the “gender clinic” model towards holistic mental health approaches is driven by six factors:

1. Changes in the patient population (4.3.1): Describes the shift from rare referrals (mostly prepubertal boys with early-onset GD) [Side note: if we go by the estimates of prevalence established by several of the authors of WPATH’s SOC-8, it would take an extremely social person 18 years to meet one person who would be part of the clinical population and qualify for medical interventions] to exponential increases dominated by adolescent females, often with no childhood history (4.3.1.1). The section notes the high rates of comorbid mental illness (depression, anxiety, self-harm, eating disorders) and neurodevelopmental conditions (ASD), often predating GD onset (4.3.1.2). It mentions the rise of nonbinary identities, not studied in original Dutch research, posing new ethical challenges (4.3.1.3), and it discusses social influence, including “rapid onset gender dysphoria“ (ROGD), a phenomenon that has been described in the research in the UK, the Netherlands, Finland and Canada, other than the United States, peer group effects, and social media, as likely factors, something that is acknowledged even by WPATH (4.3.1.4).

2. Unclear natural history and prognostic uncertainty (4.3.2): Contrasts the historical understanding (most childhood GD resolved, often into homosexuality) with the assumption that adolescent GD (regardless of onset) is permanent, which underpinned the Dutch Protocol. Cites new evidence questioning this assumption, suggesting low diagnostic stability and decline in “gender non-contentedness” into early adulthood (4.3.2.1). There is also concern that early interventions (PBs, social transition) might “lock in” identity, hindering natural development and reconciliation with sex, a concern echoed by the European Academy of Pediatrics regarding PBs creating path dependency (4.3.2.2). Notes high rates (>90%) of progression from PBs to CSH, undermining the “pause button” idea. Mentions lack of reliable methods to predict persistence.

3. Concerns about treatment-associated risks and harms (4.3.3): Highlights growing awareness of risks: unknown effects of suppressing normal puberty on bone/brain development; infertility and impaired sexual function from hormones; riskier surgeries after PBs; surgical complications; and harms highlighted by detransitioners (addressing the “false positive” risk acknowledged in the original Dutch Protocol).

4. More appropriate understanding of suicide (4.3.4): Challenges the claims that PMT is “lifesaving.” Notes that while suicidality rates are higher in GD youth, completed suicide is rare [sidenote: something that was conceded by the transgender lawyer Chase Strangio while arguing before the Supreme Court]. Argues that elevated suicidality is linked to high rates of comorbidities, not solely GD. Cites Swedish findings and lack of evidence that PMT reduces suicide mortality (which is supported by a Finnish study, WPATH's own SR, and the Cass Review). Criticizes using suicide risk to pressure parents as unethical and unsupported by evidence. References the Appleby Report condemning the misuse of suicide statistics and urging broader support beyond PBs.

5. Collapse of clinical rationale (4.3.5): Explains that the “time to think” rationale for PBs has collapsed due to high progression rates to CSH; PBs are now seen as the start of a continuous pathway. Questions the remaining rationale for PBs, especially in females, where testosterone alone suppresses estrogen, given their risks (bone/brain) and potential for lifelong dependency.

6. Lack of reliable evidence of benefit (4.3.6): States that the original goal (improving mental health by altering appearance) lacks credible evidence. SRs consistently find “very low certainty” evidence for benefits of PBs, CSH, and surgery on mental health. Concludes that every public health authority conducting an SR found the risk/benefit profile unknown or unfavorable.

And that concludes Part I of the review. I will follow up with the summaries of the other parts of the review in the coming days.