A government report evaluates gender therapy and medical care for children
BACK IN JANUARY Donald Trump signed executive order 14187, entitled “Protecting Children from Chemical and Surgical Mutilation”. He instructed federally run insurance programmes to exclude coverage of treatment related to gender transition for minors. The order aimed to stop institutions that receive federal grants from providing such treatments as well. Mr Trump also commissioned the Department of Health and Human Services (HHS) to publish, within 90 days, a review of literature on best practices regarding “identity-based confusion” among children. The ban on federal funding was later blocked by a judge, but the review was published on May 1st.
A controversial president commissioning a department headed by a controversial health secretary, Robert F. Kennedy junior, amid a big reduction in government funding for science, sounded like a recipe for more culture warring. Yet what the commission has served up is unexpectedly rigorous.
“It is a lot like the Cass Review,” says Julia Mason, a paediatrician in Oregon and one of the few left-leaning physicians in America to ask questions publicly about the nationwide embrace of puberty blockers, cross-sex hormones and surgery for children. The Cass Review, published in 2024, is the most extensive report on the subject so far, commissioned by England’s National Health Service and headed by the former president of the Royal College of Paediatrics, Hilary Cass. It found that evidence for the benefits of gender-affirming interventions on minors was “remarkably weak”.
The HHS report is more than 400 pages long, with a 173-page appendix full of charts. It is in five sections: the history; a review of existing evidence; a section on “clinical realities” in American gender clinics today; a section on ethics; and a final one on the importance of psychotherapy. Chapters were subject to peer review, and contributors included doctors and medical ethicists, but the HHS has not named the authors, pending a post-publication review process. The report largely avoids culture-war battles or terminology, though it does refer to “paediatric medical transition” (PMT) rather than “gender-affirming care”.
The summary cuts to the chase. “The evidence for benefit of paediatric medical transition is very uncertain, while the evidence for harm is less uncertain.” When medical interventions pose unnecessary, disproportionate risks of harm, “healthcare providers should refuse to offer them even when they are preferred, requested, or demanded by patients.” Claims that distressed children who do not transition face greater risk of suicide “are not supported by the evidence”.
The report includes a review of 17 previous systematic reviews on the subject, many conducted in Europe, to evaluate the evidence for benefits and harms of PMT. It finds that the overall quality of evidence on the effects of intervention is “very low”. What is more, the report says the risks of PMT include sterility, sexual dysfunction, impaired bone density, adverse cognitive impacts, psychiatric disorders, surgical complications and regret.
The ethics chapter gives perhaps the deepest bioethical analysis of the issue yet to be published (the Cass Review had no chapter on ethics). In response, Jonathan Moreno, a professor emeritus at the University of Pennsylvania, who was an adviser to Barack Obama’s bioethics commission, told the British Medical Journal that the report cited reputable bioethical texts and presented a “plausible” analysis.
The HHS report pays particular attention to the role of the World Professional Association of Transgender Health (WPATH), whose advice is embedded in American health care, even though the group does not require members to be medical professionals. In the process of developing its latest standards of care, the report claims that “WPATH suppressed systematic reviews its leaders believed would undermine its favoured treatment approach”. As a result, the report says, WPATH promoted the idea that children could consent to the treatment, and that the treatment was beneficial, even though it knew the evidence could not support either assertion.
WPATH says the HHS report “misrepresents existing research and disregards the expertise of professionals who have been working with transgender and gender-diverse youth for decades”. Trans-rights groups have also been scathing. “It is deeply troubling to see the country’s top authority on health publish a collection of recommendations that seemingly have no basis in following established health care best practices, science, or input from providers who actually administer the type of health care in question,” said Casey Pick, director of law and policy at the Trevor Project, a non-profit.
Many American medical organisations, such as the American Academy of Paediatrics (AAP) and the American Medical Association, follow WPATH’s “gender-affirming” approach. The HHS report traces how this impression of medical consensus came about, through blind delegation of authority to WPATH and its members, a chain of trust that was broken, the report says, when WPATH chose to suppress evidence. One researcher who follows the issue expressed a hope that the report could help provide a “golden bridge” for the associations to retreat, admit they had been misled by WPATH, and change course, as is starting to happen in Britain and elsewhere.
That looks unlikely. Susan Kressly, president of the AAP, dismissed the report, saying it “relies on a narrow set of data and perspectives”. By using terms like “child mutilation” and campaigning hard on a painful issue for those parents and children directly affected, the Trump administration damaged its chance of being listened to by people on the fence. In Britain, the left-of-centre Labour government has committed to implementing the Cass Review in full. In America, by contrast, many well-meaning people on the left have dug themselves into a position that is not supported by research. Dr Mason says, “The best way to judge this document is to read it.”
Source: The Economist
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