The HHS Report on Pediatric Gender Dysphoria - a summary (Part 3 of 4)
After describing the state of the evidence (Part 2), Part 3 looks at the clinical realities within the US.
The other parts are here: Part 1, Part 2, Part 4
We're once again diving back into the HHS behemoth of a report on pediatric gender dysphoria. If you've been following along, you'll know that Part 1 laid out the historical background and the shifting sands of terminology, while Part 2 waded through the murky waters of the actual evidence—or their lack thereof—for these interventions. You can catch up on Part 1 here and Part 2 here.
For Part 3 of this summary series, we're tackling what the HHS report calls ‘Clinical Realities.’ This is where the rubber meets the road, or perhaps, where the ideology meets the clinic. In Part 3, I’ll be dissecting Chapters 9 through 12, and even for someone who has read quite a bit about the laissez-faire and cavalier attitude of the American medical establishment (see, for example, this, this, or this), it was an eye-opener.
This section delves into the guidelines—or perhaps more appropriately, the glaring lack of them—that shape pediatric gender medicine (PGM) in the United States. We’ll look at the outsized influence of organizations like WPATH, how the supposed safeguards have crumbled in the last decade or more, and the rather curious response (or non-response) of major medical associations to the mounting concerns and international shifts.
If Part 2 left you wondering about the quality of the science, Part 3 will likely leave you questioning the structures and processes that have allowed these practices to become so entrenched, especially in the United States. (However, readers outside the United States will also find many references to the guidelines in their own countries.) So, grab a coffee, and let’s get into it. This is a vital chunk of the report for understanding how we got here.
PART III: CLINICAL REALITIES
Chapter 9: Review of International Guidelines
This chapter reviews clinical practice guidelines (CPGs) for pediatric gender dysphoria (GD), assessing their quality and trustworthiness. Clinical Practice Guidelines are documents designed to guide doctors and patients in making healthcare decisions.
Role and Process of CPGs (9.1): The report explains that good CPGs are meant to optimize patient care based on solid evidence, reduce inconsistencies in treatment, and offer clear guidance to everyone involved—from clinicians and hospitals to insurers, policymakers, and patients themselves. It outlines criteria from the National Academy of Medicine (NAM) for what makes a CPG trustworthy. These include being based on systematic reviews of evidence (SRs), developed by a diverse and unbiased panel of experts, considering different patient groups and their preferences, having a transparent development process that minimizes conflicts of interest (COIs), clearly linking treatment options to outcomes, rating the quality of evidence and the strength of recommendations (for example, using the GRADE system, which stands for Grading of Recommendations Assessment, Development and Evaluation), and planning for regular updates. The chapter stresses that guideline panels must carefully weigh benefits, risks, and costs, always considering patient values. Crucially, managing conflicts of interest and assessing the overall quality of a guideline (using tools like AGREE II, which is a tool to assess the quality and reporting of practice guidelines) are vital before putting it into practice.
Summary of Systematic Appraisals (9.2): The chapter focuses on a systematic review conducted by the University of York (for the Cass Review in the UK), which appraised 21 international guidelines and guidance documents using the AGREE II tool.
Methodological Quality (9.2.1): The York review found that only two guidelines, those from Sweden and Finland, were rated as trustworthy and recommended for implementation. These scored highest on quality (6 out of 7 and 5 out of 7, respectively). All other guidelines reviewed scored poorly (between 2 and 4 out of 7) and were not recommended. These other guidelines were found to lack rigor, editorial independence, and practical applicability. Specifically, guidelines that recommended pediatric medical transition (PMT) often lacked independent, evidence-based approaches, and the connection between the evidence they cited and the recommendations they made was frequently unclear.
Interdependence (9.2.2): The York review discovered an unusual level of interdependence and “circular referencing” among the guidelines that recommended PMT. Many of them heavily relied on the guidelines from WPATH (World Professional Association for Transgender Health) and the Endocrine Society (ES). Worryingly, these two organizations’ guidelines were themselves linked, with overlapping authors and WPATH even sponsoring the Endocrine Society's guidelines. The Cass Review highlighted this circularity as a significant problem.
WPATH, ES, AAP Guidelines (9.2.3): The three most influential US guidance documents—WPATH's Standards of Care Version 8 (SOC-8), the Endocrine Society's 2017 guidelines, and the American Academy of Pediatric’ (AAP) 2018 policy statement—were all assessed as being of very low quality and were not recommended for use. WPATH SOC-8 scored only 3 out of 7, and the ES guidelines scored 4 out of 7. The report criticizes the ES 2017 guidelines for making strong recommendations based on weak evidence and for prioritizing appearance and patient autonomy over the fundamental medical principle of avoiding harm. The AAP 2018 policy, which isn’t technically a CPG but is highly influential, received a very low score of 2 out of 7. It was criticized for its problematic “gender diverse” framing, which could potentially medicalize normal variations in gender nonconformity, for errors in its references, and for being reaffirmed by the AAP despite internal calls for a review.
More Recent International Guidelines (9.2.4): The chapter notes that even newer guidelines issued since the York review (from Germany, France, Poland, and the European Society for Paediatric Endocrinology or ESPE) suffer from similar flaws. These include unmanaged conflicts of interest, an upfront alignment with WPATH’s stance, a lack of reliance on rigorous systematic reviews, a failure to properly assess the quality of the primary studies they cite, a lack of clear grading for their recommendations, and a tendency to marginalize psychotherapy as a treatment option. The report concludes that issues with the trustworthiness of guidelines persist globally.
Overview of Recommendations in High-Quality Guidelines (9.3): The chapter then summarizes the recommendations from the two guidelines identified as trustworthy:
Finland (9.3.1): Finland’s 2020 guidelines emphasize psychosocial support and psychotherapy as the first line of treatment. They state that pediatric medical transition for minors is “experimental” and should be restricted to highly select cases—specifically, those with persistent childhood-onset gender dysphoria, no major co-occurring mental health conditions, and a stable gender identity. Surgery is not offered to minors in Finland. These guidelines are supported by later Finnish studies based on national registers, which showed high rates of co-occurring conditions in youth with gender dysphoria and no difference in suicide rates compared to control groups when psychiatric needs were accounted for. This represents a cautious, evidence-focused approach.
Sweden (9.3.2): Sweden’s 2022 guidelines conclude that for most youth, the risks of medical transition likely outweigh the benefits. They restrict the use of puberty blockers and cross-sex hormones to research settings or exceptional cases. Swedish guidelines prioritize comprehensive psychosocial evaluation (which includes screening for conditions like Autism Spectrum Disorder (ASD) and ADHD, and treating any co-occurring mental health issues), and support open-ended exploration of gender identity. Surgery is allowed only under exceptional circumstances for youth who are eligible for hormones. This approach embodies a precautionary principle, grounded in Evidence-Based Medicine.
Conclusion (9.4): The chapter contrasts the trustworthy Scandinavian guidelines (which prioritize psychotherapy, restrict medical interventions, and are based on systematic reviews) with the low-quality, interdependent guidelines (like those from WPATH, the Endocrine Society, and the AAP) that recommend routine pediatric medical transition without robust supporting evidence. It calls for future guidelines to strictly adhere to the standards of Evidence-Based Medicine—namely, transparency, rigor, independence, and thorough appraisal of systematic reviews—to safeguard the well-being of youth.
Chapter 10: WPATH's Standards of Care 8
This chapter critically examines the development and influence of the World Professional Association for Transgender Health’s (WPATH) Standards of Care, Version 8 (SOC-8), published in 2022. It argues that SOC-8 deviates significantly from trustworthy guideline development standards, despite its pervasive influence in the US.
Influence of WPATH in the US (10.1): The report explains that WPATH, an organization that does not require medical credentials for membership, has become the de facto authority in the US for pediatric gender medicine (PGM). This is partly due to the lack of an accredited subspecialty in this area and the fragmented nature of the US healthcare system.
Clinical Practice (10.1.1): WPATH’s SOC guidelines are deeply embedded in clinical protocols and hospital procedures across the US, while other medical societies have largely deferred to WPATH's expertise.
Medical Education (10.1.2): WPATH’s Global Education Initiative (GEI) dominates the training of clinicians in this field through certified courses, collaborations (including with the World Health Organization), and integration into medical residency and fellowship programs. WPATH certification is often encouraged or even mandated for practitioners.
Insurance Reimbursement (10.1.3): Both public (like Medicaid) and private insurers (such as Anthem, Kaiser, Aetna) rely heavily on SOC-8 to determine coverage for gender-related treatments and to define what is considered “medically necessary.” The state of Oregon, for example, officially adopted SOC-8, mandating insurance coverage for a wide range of procedures listed by WPATH, including some experimental ones like penis-preserving vaginoplasty and nullification surgeries.
Development of SOC-8 & Adolescent Chapter (10.2): The chapter notes that SOC-8 was WPATH's first attempt to create an “evidence-based” guideline, a departure from its previous version, SOC-7, which relied more on “cultural shifts.” WPATH contracted Johns Hopkins University's Evidence-Based Practice Center (JHU EPC) to conduct systematic reviews and provide methodological advice, recognizing that the chapter on adolescents would be highly scrutinized. The initial focus was on finding evidence for treatment effectiveness and for the capacity of adolescents to consent to these treatments.
Hope for Effectiveness Evidence (10.2.1): WPATH leadership reportedly expected the systematic reviews to support their established “gender-affirming” approach, planning to label their recommendations as “evidence-based” even if the quality of that evidence was low.
Adolescent Capacity to Consent (10.2.2): The JHU EPC reviewed literature provided by WPATH regarding adolescent consent capacity but found only “limited indirect evidence,” which was insufficient to support the claim that adolescents generally have the capacity to consent to these complex medical interventions. WPATH then apparently abandoned basing this claim on evidence. Instead, SOC-8 cites these insufficient studies and discusses minors consenting without parental permission. The report states that SOC-8 failed to adequately address the significant ethical challenges involved, such as a minor consenting to procedures that could lead to permanent infertility. The review cites a WPATH physician’s candid comment about the difficulty of discussing such risks with minors, likening it to talking to a “blank wall.”
Treatment Effects (10.2.3): The JHU EPC completed systematic reviews on treatment effects, but WPATH perceived the findings as unfavorable to their established practices and subsequently suppressed them (this is detailed later in the chapter). SOC-8 falsely claims that a systematic review wasn't possible due to a lack of studies. Despite this, SOC-8 recommends pediatric medical transition with vague criteria, such as gender dysphoria being “sustained over time.” The recommendations were crafted in a way that would allow any “willing” provider to intervene, even in patients with co-occurring mental health conditions.
Process of Creating SOC-8 (10.3): This section details how the development of SOC-8 deviated from the standards for trustworthy guidelines set by organizations like the National Academy of Medicine (NAM) and the World Health Organization (WHO).
Conflicts of Interest (COI) Management (10.3.1): The HHS report argues that WPATH failed to adequately manage significant financial and intellectual conflicts of interest among those developing SOC-8. The chair of the SOC-8 committee, Eli Coleman, had several COIs, including being the lead author of SOC-7, having published extensively in favor of pediatric medical transition, and receiving funding from the pro-trans Tawani Foundation, which also funded SOC-8. Disclosures of these COIs were reportedly made late in the process. The JHU EPC itself observed widespread COIs. Some WPATH members argued that COIs were unavoidable or irrelevant in such a politically charged field. The report cites examples, such as SOC-8 contributors Karasic and Schechter serving as paid legal experts for cases related to gender transition during SOC-8’s development. Schechter reportedly worried that acknowledging the weak evidence base could negatively impact his legal cases, a stance Coleman deemed ethically justifiable. The HHS report argues that WPATH engaged in “panel stacking” by requiring WPATH membership for contributors, favoring “advocates” for medical transition, and discouraging dissenting opinions.
Suppression of Evidence (10.3.2): This section details how WPATH commissioned over 12 systematic reviews from the JHU EPC but suppressed most of them after finding the results unfavorable to medical interventions. The JHU EPC confirmed that WPATH restricted the publication of these reviews. WPATH then imposed a new approval process requiring its leadership to pre-approve the content and conclusions of any manuscripts to ensure they aligned with WPATH’s goals, yet mandated a disclaimer stating WPATH was not involved. Only one systematic review (Baker et al. 2021) was published under this policy, effectively blocking critical safety appraisals. When the systematic reviews did not support their views, WPATH shifted to using a consensus-based method (the Delphi method), which the HHS report argues is not a substitute for rigorous evidence.
Redefinition of Medical Necessity (10.3.3): The report shows that SOC-8's strong recommendation for pediatric medical transition as “medically necessary” was strategically crafted. It traces how the language in drafts shifted from focusing on patient “wishes” to patient “needs,” based on requests to strengthen arguments for insurance coverage and legal cases. WPATH advised clinicians to use “Endocrine Disorder” ICD (International Classification of Diseases) codes instead of codes for Gender Dysphoria. This reframing aimed to bypass safeguarding measures and center patient desire, with one member quoted as saying the guidelines allow any willing clinician to meet patient wishes. WPATH leaders reportedly acknowledged that this redefinition was done primarily for insurance and legal leverage.
Legal and Political Considerations (10.3.4): The chapter provides evidence suggesting that the language in SOC-8 was manipulated to achieve legal and policy goals. It cites “social justice lawyers” advising against rigorous reviews that might reveal a weak evidence base. Contributors Schechter and Karasic reportedly raised concerns about how certain language might impact court cases. There was advice against using age minimums for treatments to avoid legal challenges, and editorial input was allegedly aimed at helping ACLU lawyer Chase Strangio. Eli Coleman is quoted as urging a stronger “defense” for court cases. A contributor is quoted as prioritizing political impact over scientific accuracy. Karasic reportedly emphasized the statement’s importance for US insurance claims and lawsuits. The report also cites Coleman's 12-point plan, which anticipated criticism and aimed to build consensus among medical groups for legal leverage, acknowledging that endorsements for SOC-7 had been inaccurately claimed.
Elimination of Age Minimums (10.4): This section details how initial age minimums proposed for SOC-8 (e.g., 14 for cross-sex hormones, 15 for mastectomy) were removed due to political pressure, bypassing even WPATH's own revised processes. First, the office of HHS Assistant Secretary Levine reportedly expressed concern, leading WPATH to downgrade the age minimums to mere “suggestions” without re-validating this change. Then, the American Academy of Pediatrics (AAP) allegedly threatened to oppose SOC-8 unless all age thresholds (except for phalloplasty) were removed. WPATH leaders capitulated to this pressure despite private reservations, issuing a correction erratum after the initial publication of SOC-8 to remove the age minimums. Coleman admitted that this significant change bypassed even the Delphi consensus process that WPATH had adopted.
Continued Reliance on SOC-8 (10.5): Despite public reporting in major media outlets (like the New York Times, The Economist, and the British Medical Journal) about its flawed development, SOC-8 remains highly influential in the US. The report notes that only the plastic surgeons’ society adopted a more cautious stance following the Cass Review in the UK. It highlights that amicus briefs submitted to the US Supreme Court (from the AAP and 21 other organizations, and from 11 academics) still described SOC-8 as “established, evidence-based,” and reliable, ignoring the documented issues with its development. The US Department of Justice, despite being aware of these issues, also reportedly cited WPATH and SOC-8 as authoritative in a legal brief.
Chapter 11: Collapse of Medical Safeguarding
This chapter argues that the original safeguards of the Dutch Protocol for pediatric medical transition (PMT) have been dismantled in the US. This has led to expedited, "child-led" processes that prioritize patient goals over comprehensive assessment and careful consideration of long-term outcomes.
Dutch Protocol Relaxation (11.1): While WPATH's SOC-8 cites the Dutch studies as the most robust evidence and claims to require a comprehensive assessment (contrasting it with unsupported “limited/no assessment” approaches), a Reuters investigation found that US clinics often do not follow the lengthy and thorough assessment processes characteristic of the original Dutch Protocol.
Rapid Interventions in the US (11.1.1): Many US clinics reportedly prescribe hormones on the very first visit if no immediate “red flags” are identified. This is a stark departure from the Dutch model.
Dutch Researchers' Concerns: The report quotes Dutch researchers like de Vries and Steensma, key figures in developing the Dutch Protocol, distancing themselves from the current US model. They note that changes in patient demographics (e.g., more adolescent females, more co-occurring mental health conditions) raise serious questions about the applicability of their original findings to today's patient population. They also confirm that the “child-led” approach common in the US is “not our approach.”
Deviation on Surgery Ages: The chapter highlights another significant US deviation: allowing surgeries like mastectomy and genital surgeries before adulthood, which was not part of the original Dutch Protocol.
Is PMT “Rare”? (11.2): The report challenges claims made by advocates of pediatric medical transition (including a past AAP president) that these interventions are “rare,” arguing that this framing is used to minimize legitimate concerns.
Prevalence Data: It cites a JAMA (Journal of the American Medical Association) study, which found that 1 in 1,000 US 17-year-olds received cross-sex hormones between 2018 and 2022. While the study authors called this “rare,” the report points out that comparable rates for Type 2 diabetes in adolescents are considered an “epidemic.”
Rarity vs. Ethical Concerns: The report argues that even if interventions were rare, this would not negate ethical concerns, citing historical examples like the Tuskegee syphilis study. It also questions the denominator used in such “rarity” claims (e.g., total adolescents vs. only trans-identified youth vs. only clinic-referred youth). [As an aside, I will refer you to a comment published alongside the JAMA article which I coauthored (and which, to this day, has not been refuted by the authors of the JAMA article), where we calculated that this 1-in-1000 rate for adolescents receiving CSH is between 14.7 and 21.7 times larger than the prevalence estimates for the clinical population that should receive medical interventions, according to WPATH SOC-8’s own authors.]
Medicalization as the Norm in Clinics: Clinic reports from institutions like the University of Michigan and Washington University in St. Louis are cited, suggesting that for youth referred to gender clinics, medicalization (receiving hormones or blockers) is the norm, occurring in 65-67% of cases. WPATH itself criticized the Cass Review's premise that non-medical options work for “most adolescents,” implying that WPATH believes medical intervention is necessary for the majority.
Shift in Objectives & “Assessment” Meaning (11.3): The chapter contrasts the original goal of assessment in the Dutch Protocol (which was to predict lifelong transsexuality and ensure suitability for transition) with the US “gender-affirming” model, which prioritizes child autonomy and the achievement of “embodiment goals” (i.e., aligning physical appearance with gender identity).
Lack of Consensus on Assessment: A systematic review cited in the report found no consensus on the aim or approach of assessment in pediatric gender medicine.
“Trans Kids Know Who They Are”: Proponents of the affirmative model now often argue that “trans kids know who they are,” and that detransition is merely part of a “gender journey,” not an indication of treatment failure (quoting Dr. Rafferty of the AAP). The HHS report argues this shifts the focus from clinical improvement and well-being to simply fulfilling patient desires. [In the chapter on ethics, which I will cover in Part 4, the HHS review went on to equate providing non-beneficial care upon request to unethical medical consumerism (in other words, “caveat emptor”), which is a violation of professional integrity.]
Diagnostic Model Unsupported: The original diagnostic model for predicting persistence of gender dysphoria is also unsupported by evidence; there is no reliable test to predict who will persist in a transgender identity. The Cass Review found that a diagnosis of gender dysphoria is not predictive of future outcomes.
Puberty Blockers as a Pathway, Not a Pause: The report highlights the shift in viewing puberty blockers from a reversible “pause button” to the first step on an inevitable medical pathway. It cites a Supreme Court brief by McNamara arguing that puberty blockers and cross-sex hormones constitute a single standard of care because the high rate of progression from blockers to hormones proves that these youth “are indeed transgender.”
Ambiguity in SOC-8 (11.3.1): While SOC-8 seems to advocate for caution by mentioning a “comprehensive biopsychosocial assessment,” it nonetheless recommends using the ICD-11 diagnosis of “Gender Incongruence.” This diagnosis only requires a sense of incongruence between experienced gender and sex characteristics, not necessarily distress or impairment (which is required for a DSM diagnosis of Gender Dysphoria). The report argues that this effectively medicalizes identity itself. It highlights the tension between efforts to depathologize transgender identity and the need for a medical diagnosis to secure insurance reimbursement. The report quotes clinicians expressing disagreement and frustration over assessment requirements during the drafting of SOC-8. Some reportedly saw comprehensive assessment as “gatekeeping" or even “conversion therapy,” while others wanted the focus to be solely on achieving the patient's “embodiment goals,” like developing a deep voice or breasts.
SOC-8 Guardrails Abandoned (11.3.2): The HHS report argues that the flexibility inherent in SOC-8 allows for wide variation in practice and even non-adherence to its stated (though ambiguous) standards. It cites leaked WPATH discussions showing that some members skip evaluations altogether. Some clinician advocates reportedly argue that assessment should only inform patients about interventions and should not act as a barrier or “gatekeep,” claiming that differential diagnosis (distinguishing gender dysphoria from other conditions) is pointless or even harmful (citing Dr. Turban). The report quotes Dr. Garofalo (from Lurie Children's Hospital) saying that assessment isn't needed to determine identity because the “answer lies within the young person,” and that the provider's job is to help them find “authentic” solutions and “move parents along.” It also quotes Dr. Amy Tishelman (formerly of Boston Children’s) expressing unhappiness with assessment being reduced to simply approving medical intervention. Dr. Eckert (of Anchor Health) is quoted as saying, “If you are trans, I believe you,” that minors are best equipped to decide their own medical paths, and that therapy isn’t mandatory because being transgender isn’t a pathological condition.
Collapse of Assessment Times (11.3.3): The chapter provides several examples of drastically reduced assessment times in US clinics:
Boston Children's Hospital (11.3.3.1): Reportedly reduced assessment periods from over 20 hours in 2013 to approximately 2 hours by 2021. This change was deemed “shocking” and “reckless” by former staff but defended by current directors.
Children’s Hospital Los Angeles (11.3.3.2): Dr. Olson-Kennedy reportedly approved interventions after “a couple of hours.” The clinic faced a lawsuit alleging approval of puberty blockers for a 12-year-old after just one visit, with no input from mental health professionals, and using warnings of suicide risk despite the child having no history of suicidality.
Lurie Children's Hospital (11.3.3.3): Dr. Garofalo described needing to meet a patient's desire for hormones while simultaneously working to “move parents along” to consent.
Seattle Children's Hospital (11.3.3.4): Dr. Tordoff stated that co-occurring mental health conditions didn’t preclude hormone treatment (as hormones supposedly help these conditions) and that 18-year-olds needed no assessment at all.
UCSF Benioff Children's Hospital (11.3.3.5): Dr. Ehrensaft was described by a colleague, Dr. Sherer, as doing “brief assessments” primarily to “rubber-stamp” approvals for medical interventions.
Planned Parenthood (11.3.3.6): Has become a major provider of hormones, offering expedited access through an “informed consent” model, potentially starting at age 16. Concerns have been raised about the verification of adult consent in these settings.
The Whistleblowers (11.4): The report contrasts public claims made by advocates of pediatric medical transition (such as McNamara and Janssen) of slow, rigorous assessment processes with accounts from whistleblowers within the field.
Edwards-Leeper & Anderson (11.4.1): These were among the first prominent US whistleblowers. In 2021, they warned in the Washington Post that youth were being “rushed” into care due to a flood of referrals and the prevailing political climate, leading to “sloppy, dangerous care.” Dr. Anderson reportedly resigned from USPATH (the US arm of WPATH) after being reprimanded, and attempts were made to silence her. Dr. Marci Bowers (then WPATH president-elect) initially echoed concerns about outcomes and the impact of treatments on fertility, sexuality, and intimacy, but later apologized to WPATH for her comments.
Jamie Reed (11.4.2): Reed, a former case manager at the Washington University Transgender Center in St. Louis, disputed claims made by the clinic's co-directors about thorough assessments and strict criteria. Reed testified that the clinic's endocrinologist, Dr. Lewis, did not require a formal diagnosis of gender dysphoria to prescribe hormones. The New York Times corroborated Reed’s story, finding that patients indeed received hormones after just one visit, often with no input from mental health professionals. Reed described practices such as using copy-pasted approval letters, maintaining a “red flag list” that tracked severe co-occurring conditions which were then ignored by physicians, a patient regretting mastectomy and wanting “her breasts back” (a concern ignored by the surgeon), and another patient suffering vaginal tearing due to testosterone-induced atrophy. Reed reported being told to “Get on board, or get out” and facing accusations of transphobia for raising these concerns. Reed now advocates for restrictions on these medical interventions for minors.
Tamara Pietzke (11.4.3): Pietzke, a therapist in Washington state, disclosed that a clinic expert, Amber Rolfe, approved hormones for highly vulnerable youth despite Pietzke’s refusal to sign off. One case involved a 13-year-old with multiple diagnoses, a severe trauma history, and communication issues (who communicated via graphic pornography and had never actually asked for hormones). Rolfe reportedly dismissed Pietzke’s concerns, insisted that co-occurring conditions were not contraindications for hormones, and questioned Pietzke’s potential bias. Pietzke resigned from her position.
Eithan Haim (11.4.4): Haim, a surgeon, revealed that Texas Children’s Hospital (TCH) continued to provide pediatric medical transition services to minors despite publicly claiming they had ceased these practices. Dr. Haim leaked documents to journalist Christopher Rufo. He subsequently faced unusual federal felony HIPAA charges, which alleged intent to harm the hospital, not the patients. These charges were widely seen as retaliatory “lawfare.” The charges were eventually dismissed with prejudice after multiple flawed indictments and the revelation of the prosecutor's financial ties to TCH.
Chapter 12: Medical Association Response
This chapter examines why major US medical and mental health associations (MMHAs) have continued to support WPATH's SOC-8 and pediatric medical transition (PMT) despite growing evidence concerns and significant international shifts towards more cautious approaches. It argues that institutional dynamics and external pressures have played a key role in this stance.
Role of MMHAs (12.1): The report explains that MMHAs (such as the American Academy of Pediatrics (AAP), American Psychiatric Association (APA), American Medical Association (AMA), and Endocrine Society (ES)) are central in the fragmented US healthcare system for setting standards of care, educating clinicians, publishing influential journals, and advocating for policies. These organizations typically limit membership to professionals and enforce codes of conduct. The report acknowledges that their authority relies on a perception of scientific rigor but warns that they are not immune to bias, groupthink, or disproportionate influence from specialized subcommittees (especially if an argument is framed as a civil rights issue), potentially becoming echo chambers that suppress dissent. It cites historical examples where MMHAs resisted evidence-based reforms (like changes in advice for peanut allergies or the efficacy of certain knee surgeries) when members’ established practices or interests were threatened. The HHS report highlights MMHAs’ reliance on WPATH (for instance, the Endocrine Society’s guideline development was sponsored by WPATH) and raises concerns about conflicts of interest in guideline revisions (e.g., the lead of the ES guideline revision, Dr. Safer, being linked to WPATH). It criticizes MMHAs like the APA, AACAP (American Academy of Child and Adolescent Psychiatry), and AAP for a lack of transparency, for rejecting internal calls for debate and review of their positions, for suppressing critical perspectives at conferences, and for platforming misinformation while ignoring critiques (e.g., the APA’s GAPC guideline, and the AAP reaffirming its flawed 2018 policy statement on gender affirmation). The report also cites instances of listserv bans on discussing the Cass Review by APA affiliates (Division 39, Pennsylvania Psychological Association), citing potential harm to LGBTQ+ members, and reports of therapists being reprimanded for expressing concerns (Illinois Psychological Association).
Factors Contributing to Neglect of Evidence/Debate (12.2): The chapter explores reasons for the reluctance of US MMHAs to engage with the growing evidence and ethical concerns surrounding pediatric medical transition, citing Dr. Hilary Cass's view that US doctors are “out of date” on this issue.
Deferral to Specialists: Generalist leaders within MMHAs often defer to specialized committees (e.g., those focused on LGBTQ+ issues), viewing them as the experts. However, these committees are often composed of providers of pediatric medical transition who may have significant conflicts of interest, a situation unlike that in more established medical fields with robust research bases.
Civil Rights Framing: Framing pediatric medical transition primarily as a civil rights issue has led many professionals and institutions to adopt supportive positions uncritically, potentially influenced by personal connections and compassion, rather than a rigorous assessment of medical evidence.
Institutional Defensiveness: Having previously promoted pediatric medical transition and often denounced critics, MMHAs have reacted defensively to international shifts and emerging critical evidence, as these are perceived as challenging their credibility and past endorsements. (An exception noted is the American Society of Plastic Surgeons, which adopted a more cautious stance after the publication of the Cass Review.)
Suppression of Dissent: The report argues that the suppression of dissenting views obscures the lack of true consensus within the medical community. It notes the hostility faced by researchers and clinicians who question pediatric medical transition or study topics like detransition or social contagion. This hostility comes from publishers, professional societies, and institutions. There is evidence of self-censorship among professionals due to fears of reputational damage, amplified by activist tactics that label critics as “anti-trans.” The report quotes Dr. Cass on the fear, vilification, and stifling of debate, which ultimately harms both the youth seeking care and the conduct of proper research.
Conclusion (12.3): The HHS report argues that the reliance of US MMHAs on WPATH has led to the importation of methodological and ethical flaws, which have then been propagated throughout the US healthcare system. It criticizes these associations for prematurely issuing advocacy-driven recommendations without adequate scientific backing, thereby degrading the norms of open inquiry and evidence-based practice. The report concludes that MMHAs, whose self-regulatory privilege rests on prioritizing patient and societal interests, have failed in their handling of pediatric medical transition due to institutional biases, reliance on advocacy groups, and internal politics. This, the report suggests, has undermined their credibility and effectiveness, and ultimately, has not served the best interests of vulnerable patients.
This concludes the summary of Part III: Clinical Realities. Part 4 will cover the final parts of the HHS review, including the all-important chapter on ethics.
" this shifts the focus from clinical improvement and well-being to simply fulfilling patient desires."
Desires at that moment, no less!