For years, proponents of pediatric gender medicine appeared to have an ironclad medical consensus behind them. “Gender-affirming care” — including puberty blockers, cross-sex hormones, and even irreversible surgeries — was simply a medical best practice. Many of them claimed these treatments were “life saving,” suggesting there was no difference between them and, say, the suite of interventions oncologists might prescribe for cancer patients.
But the consensus was always a mirage — and this week, at least among major US medical groups, it officially vanished.
On Tuesday, the American Society of Plastic Surgeons came out in opposition to providing gender-transition surgeries to minors. The recommendation, the first of its kind from a mainstream medical association, was published in a nine-page policy statement that marks a watershed moment in these debates. It’s part of a broader rethink among many experts, a reminder that science can trump ideology when investigators follow time-tested, evidence-based processes.
To wit, the ASPS examined the thorny cross-section of scientific research and medical ethics that inform the question of whether to provide gender-transition interventions for minors. After considering the weakness of the relevant scientific evidence and the balance of risks versus benefits, the organization urged its 11,000 members to delay gender-transition surgeries — including breast removal and augmentation, penis inversions, and facial-feminization surgery — until patients reach age 19.
The document — which, while addressed to plastic surgeons, is not a clinical-practice guideline — also cautions that the prospect of treating gender distress in minors with blockers and hormones raises serious ethical concerns due to the shaky state of the supporting science, the challenges of procuring minors’ informed consent, and the irreversibility of hormones in particular.
While supporters of gender-transition surgeries often falsely characterize them as rare, approximately 1,000 minors received such interventions annually in recent years — overwhelmingly mastectomies for girls who identify as male or nonbinary.
The ASPS’s position is grounded in systematic literature reviews — the gold standard of scientific evidence — and pays deference to Britain’s mammoth Cass Review of the field. Accordingly, the document validates the evidence-based-medicine approach to this discipline advocated by the quietly influential — and much-maligned by transgender activists — Society for Evidence-Based Medicine.
The policy document points to widely debated and criticized research that has suggested that, absent a gender transition, most youths with gender dysphoria will grow out of it. It goes on to point out that even highly experienced clinicians are unable to reliably predict which adolescent patients will persist in their gender-related distress. It then tips its hat to the massive report on pediatric gender medicine commissioned by the US Department of Health and Human Services, which was published in its final form in November and has been roundly dismissed as politically tainted, biased and therefore irrelevant by transgender advocates.
The ASPS continues: “The HHS report underscores that this uncertainty has significant ethical implications: when the likelihood of spontaneous resolution is unknown and when irreversible interventions carry known and plausible risks, adhering to the principles of beneficence and nonmaleficence (i.e., promoting health and well-being while avoiding harm) requires a precautionary approach.”
Those bold assertions are all but guaranteed to enrage and demoralize transgender activists, especially given that this policy statement arrives amid attacks on pediatric gender medicine by the Trump administration as well as a larger fracturing of the global elite consensus about pediatric gender medicine. The cracks have fast expanded after multiple systematic literature reviews found that the evidence backing the benefits of giving gender-transition interventions to minors is weak and uncertain.
Health authorities in a swath of European nations and the ruling Labour party in Britain sharply restricted minors’ access to gender-transition interventions. In the United States, just more than half of states, all of them red, have banned these practices. And on Friday, a jury in Westchester County awarded $2 million in damages to a detransitioner after her attorney convinced a jury that her psychologist and plastic surgeon had deviated from best practices and harmed her by removing her breasts when she was 16 years old. It was a landmark case — the first decision of its kind — and is expected to serve as a catalyst for others.
The ASPS’s position statement calls into question the logic pushed by many transgender activists that patient autonomy should be paramount — even absolute — among minors seeking these interventions. The document states that “patient autonomy is more properly defined as the right of a patient to accept or refuse appropriate treatment; it does not create an obligation for a physician to provide interventions in the absence of a favorable risk-benefit profile.”
Wading into the policy debate, the ASPS asserted that it opposed the criminalization of gender-transition interventions for young people and other “punitive legislative approaches.” A few states — Idaho, Oklahoma and Florida among them — impose such harsh criminal penalties. And yet, the ASPS stopped short of explicitly opposing bans that impose only civil consequences, which comprise the vast majority of state bans on pediatric gender medicine.
The ASPS policy document’s age cut-off of 19 for surgeries puts the ASPS in line with policies of the Trump administration as it has engaged in a whole-of-government assault on what remains of the pediatric gender medicine field.
Yet leaders at the ASPS saw the new recommendations as necessary. Dr. Scot Glasberg is a plastic surgeon in private practice in New York and a past ASPS president. He was not directly involved with the new policy statement but said he was intimately familiar with its development. He said the organization selected age 19 as a cutoff because by that point young people are safely out of puberty.
“This entire statement revolves around a vulnerable population,” Glasberg told UnHerd. “The ages of development are key.” And given the weakness of the evidence base, he continued, “we felt it would be best to recommend to wait until the age of 19” to allow young people time to mature.
Facing what is sure to be considerable backlash from liberal groups and transgender advocates, Glasberg asserted that the ASPS’s work on this document was fully independent of the Trump administration. “We have the beauty as an organization to be out of the line of politics,” Glasberg said. “We deal with science and evidence and data, and that’s why we made the decision we did.”
The ASPS had telegraphed its discomfort with gender-transition interventions for minors during the Biden administration. In August 2024, the organization made clear that it did not endorse such practices. The organization’s president at the time, California plastic surgeon Dr. Steven Williams, said in an Instagram live interview the following month that he wouldn’t commit to the ASPS coming out in opposition to those bans.
Yet major LGBTQ and liberal nonprofits, including GLAAD, the Human Rights Campaign, and the ACLU, have continued to routinely make the false claim that all major medical organizations endorse what they call gender-affirming care for minors.
As recently as December, the ACLU made this claim in a statement about its efforts to combat the Trump administration’s threats to strip Medicaid funding from hospitals that provide gender-transition interventions to patients under age 19. The ACLU release stated: “The administration’s proposal seeks to block the provision of evidence-based, medically necessary care for transgender people under 18 — care that is supported by every major medical association in the United States, including the American Medical Association and the American Academy of Pediatrics.”
After UnHerd challenged the ACLU over the veracity of its statement, a representative replied: “The ASPS opposes bans on gender-affirming medical care, like those the ACLU has challenged in court, so your claim is misleading at best.” Contacted for further comment after the ASPS released its new policy statement, the ACLU didn’t reply. GLAAD and HRC also didn’t reply to a request for comment.
The ASPS’s policy statement is already providing ample fodder for the legal profession.
Alabama Attorney General Steve Marshall, who has tangled with the ACLU in court, was eager to provide a comment. “For years, legal advocacy groups like the ACLU have worked hand-in-hand with medical interest groups,” he said, “to manufacture a narrative for use in court that providing sex-change procedures to children is medically necessary and recommended by every major medical organization,” he told UnHerd. “The claim has always been false, and I am glad that responsible medical organizations are finally beginning to put patient safety and evidence-based review ahead of ideology.”
Legal experts said the ASPS appeared eager to ward off attempts by litigators to leverage its new policy document in detransitioner lawsuits against plastic surgeons. More than two dozen suits have been filed by such plaintiffs so far, including some that, like the case that won the judgment in Westchester on Friday, include a plastic-surgeon defendant.
A critical statement in the ASPS document reads: “This position statement is not a retroactive judgement, but a forward-looking response to evolving evidence.”
Yet Charles LiMandri — a partner at the California law firm LiMandri and Johnna, which is behind two of the most famous detransitioner lawsuits — still sees an opening. “What the opposition has always said,” LiMandri told UnHerd, is that pediatric gender medicine “is evidence-based medicine, and that the science was settled and supportive. Those were lies.” He continued: “The fact that people are coming out now and saying there never was good science to support this proves those were lies. So in one sense they could say, ‘Well, the new ASPS standards can’t be applied retroactively.’ But on the other hand, they can’t deny the fact that if there’s no evidence for it now, there never was. And they said there was.”
Adam Deutsch, a personal-injury attorney in White Plains who represented the plaintiff in the detransitioner lawsuit, referenced the difference, dissected during the three-week trial, between the 16-year-old girl’s desire for surgery and the responsibility of the care providers to determine whether it was in a minor’s best interest. He said that the ASPS position statement validated his successful effort to point the finger at the defendants.
Deutsch noted another element of the policy document that dovetailed with his client’s lawsuit: what he interpreted as the ASPS asserting that plastic surgeons needed to conduct their own due diligence when screening patients and not merely rely on the independent word of a referring mental-health professional.
The attorney suggested that the ASPS might be putting more doctors on notice than just those who care for minors. He said he thought such a position by the ASPS would place greater pressure on surgeons when considering performing gender-transition surgeries on adults, as well.
The once-impenetrable edifice of gender activism is beginning to crumble.
This probably isn't as much as she could have gotten and it likely won't be enough to make malpractice insurers immediately balk and change their policies.
But as the first trial verdict, it sets a precedent. The first brick has fallen, and the second won't be far behind.
Soon enough we'll see $5m, $10m judgements and the liability insurers will pull the plug. When every person who passes through an affirmation-only system is a potential multi-million dollar lawsuit payout, nobody will be willing to back these butchers.
Last month, Dr. Gordon Guyatt, an authority on medical research, capitulated to a transgender activist mob and undermined his own field in the process. Guyatt, a professor at McMaster University in Canada, co-founded the field of evidence-based medicine in the Nineties. His team has been conducting systematic reviews of the evidence behind gender-transition treatments for youths — and like several other researchers before them, they have found the evidence weak and uncertain.
Yet in response to ferocious pressure from trans activists, Guyatt disavowed his research team’s besieged funder; explicitly denounced the use of his work to justify bans of these controversial interventions; and contradicted his own findings about the evidence base. Given Guyatt’s academic prowess, his recent about-face has stunned critics of pediatric gender medicine. (Guyatt declined my requests for comment.)
Guyatt’s capitulation follows a concerted campaign by transgender activists to smear the trio of systematic reviews that his team recently published, suggesting Left-wing cancel culture still poses a threat to academic freedom and free inquiry where pediatric gender medicine is concerned.
Evidence-based medicine is a revolutionary meta-scientific discipline that has sought to synthesize the analysis of research findings. The goal is to determine the quality of evidence about any particular medical practice, support more precise and transparent treatment guidelines, and ultimately improve clinical decision-making. The legitimacy of the field depends, at least in part, on academics’ independence and detachment from the political fray.
This year, the McMaster team published the first three of five systematic reviews on gender-transition interventions for youths: on puberty blockers, cross-sex hormones, and gender-transition mastectomies. While the mastectomy review was the first of its kind, the others were but the latest in a solemn parade of such reviews by researchers across the Western world. McMaster concluded that the evidence in all three treatment areas was weak and uncertain. Similar findings from researchers across the Atlantic have prompted health authorities in a swath of European nations to sharply restrict minors’ access to gender-transition treatments.
Guyatt’s research was funded by the US-based Society of Evidence-Based Gender Medicine, a group founded in 2019 with a mission to scrutinize the scientific evidence backing gender-transition interventions for youths. As determined by academics in a 2024 systematic review commissioned to support the Cass Review of pediatric gender medicine in Britain, this field is sorely lacking for guidelines that pass evidence-based muster. SEGM sought to help fill that void. In 2021, it commissioned the systematic reviews from Guyatt’s team at McMaster; the project was headed by Dr. Romina Brignardello-Peterson, an associate professor of health-research methods.
In North America, SEGM has prompted skepticism about the safety, efficacy, and ethics of these interventions. Recognizing the nonprofit’s mounting influence, trans activists have campaigned to poison its reputation. In December 2023, the Southern Poverty Law Center released a report about a supposed “pseudoscientific” network of anti-LGBTQ groups, including SEGM, that sought to harm trans youth. The report sought to tie SEGM to funding streams that also back conservative anti-LGBT organizations. But the allegations were misleading, given that these were generic donor advisory funds that, as it happens, also channel millions of dollars in donations to SPLC itself; the SPLC officially designated SEGM a hate group in June 2024, which catalyzed the activist uprising against Guyatt’s team.
Guyatt caved. On Aug. 14, he and four of his colleagues published a statement on McMaster’s website in which they disavowed SEGM. “When the agreement started in 2021, the organization appeared,” they tersely wrote, “to be legitimately evidence-based.” They offered no evidence to back this cryptic take-down. The McMaster team also lamented how its own work was being “misused to harm trans youth,” calling it “unconscionable to forbid clinicians” to provide such interventions.
Dr. Steven Montante, a plastic surgeon in Richmond, Va., was among the four review-paper coauthors who didn’t sign the statement. “I don’t necessarily agree that he has the authority to dictate” how his work is used, he said of Guyatt. “To be so prescriptive waters down the notion of why we do these systematic reviews, and the notion of evidence-based medicine. There should be some level of detachment.”
“Why didn’t the institution defend the science?” said Dr. Paul Garner, an emeritus professor of evidence synthesis in global health at Liverpool School of Tropical Medicine. “I see this is an institutional failure.” He added: “This is obviously a toxic ideological area.”
Montante and other sources with knowledge of Guyatt’s team told me that the statement was a direct response to activist pressure. The activist campaign was driven in part by an incendiary, anonymous Instagram account that targeted the researchers and their ties to SEGM and demanded retractions of the review papers. The social-media posts featured videos of activists confronting Guyatt and Brignardello-Peterson and, in a dubious reference to the SPLC report, claiming that SEGM “shares funding streams with US white-nationalist organizations and lobbies for discrimination against, and ultimately extermination of, trans people.” Eventually, the researchers came under mounting internal pressure, as well, from trans advocates at McMaster and university administrators, Montante and other sources told me.
The pressure campaign spilled into broader view on July 12, when a group of physicians and academics, including one from McMaster, published an editorial in the university’s local paper denouncing the Guyatt team’s work as “pseudoscience,” absent any direct evidence. The editorial relied on the same brand of guilt-by-association that SPLC levied against SEGM’s supposed ties to anti-LGBTQ conservative groups.
Speaking anonymously for fear of reputational harm, a number of evidence-based-medicine experts told me that by crumbling in the face of activist pressure, Guyatt in particular called into question his capacity to provide dispassionate analyses about any scientific subject. Critics also expressed astonishment that Guyatt’s team announced it had made a donation to Egale Canada, which calls itself “Canada’s leading organization for 2SLGBTQI people and issues” and calls gender-transition treatment “life-saving.” This is not an evidence-based claim, and some experts told me such tithing represents a brazen conflict of interest. Also egregious, experts told me, was the McMaster statement’s use of activist rhetoric. This includes characterizing gender-transition treatment as “medically necessary,” despite the team’s own conclusions that the efficacy of these treatments remains essentially unknown.
In 2023, when Guyatt sat on a panel at SEGM’s conference in New York, he sounded a different note. Asked whether it was acceptable to call pediatric gender medicine “life-saving” and “medically necessary” when it’s backed only by low-quality evidence, he said: “Of course not.” The rational approach, he said, would be “not to say it’s medically necessary, it’s to say we are putting an extremely high value on autonomy.” Indeed, the recent statement from Guyatt’s team asserted that when a treatment is backed by low or very low certainty evidence then the “high respect for autonomy becomes particularly important.”
Conservative US policymakers have argued that if doctors fail to self-police and protect children from themselves, the state is justified in stepping in. On a July 30 call, according to Montante, Guyatt expressed his unhappiness that his team’s papers had been cited in a US Department of Health and Human Services report on pediatric gender medicine. Published in May, the report concluded that the known and potential harms of these medical interventions were so concerning that providing them was unethical.
Another inside source said that administrators told Guyatt’s team that if they didn’t distance themselves from SEGM, they’d risk being branded unfriendly to LGBTQ interests and thus might lose funding opportunities from the Canadian Institutes of Health Research.
Montante provided me with emails that Brignardello-Peterson, the leader of the SEGM-commissioned reviews, sent in February on her and Guyatt’s behalf to the review authors. Expressing unhappiness that “our work is being misused and may be causing harm,” the pair proposed adding a paragraph to all the reviews’ conclusions emphasizing the importance of patient autonomy and denouncing policies restricting medical interventions. When Montante’s objected that such a post-hoc edit “may undermine the research,” they scrapped that idea. Instead, they proposed sending a letter to the editor to the journals that had published their reviews, which Montante and three others declined to sign and that was similar to the statement ultimately published in August.
More recently, Brignardello-Peterson and Guyatt have sought to divorce themselves from two reviews nearing publication. This includes a paper on social transitions (changing names, pronouns, style of dress), and another on binding breasts and “tucking” the penis and scrotum. Montante, who is a co-author of the latter pending paper, said the McMaster team wants a wholesale abandonment of authorship, leaving only him and one other co-author, an independent researcher. Such a sweeping disavowal of prominent, nearly published scholarship is extremely unusual in academia.
According to sources close to the matter, McMaster also sought to cancel various independent commissions that individual university researchers received from SEGM. This has jettisoned, for example, years of work on an evaluation of the influential trans-care guidelines for adolescents published in 2022 by the World Professional Association for Transgender Health. The outstanding systematic reviews, Montante insisted, should be published. “Let the work stand for itself,” he said. Of his many dealings with SEGM, he said: “I’ve never gotten any kind of vibe or any kind of perception that this was some kind of anti-trans group.”
In a recent interview, Guyatt said he had evidence that SEGM at least effectively supported bans of pediatric gender medicine. But he failed to produce any such evidence. Otherwise, Guyatt made clear that he’d prioritized protecting his reputation in the eyes of one faction of the gender-medicine war rather than adhering to the principles of academic freedom. Regardless of the truth, he said, he had to cut ties with SEGM because associating with a group with such a toxic reputation meant getting “tarred and feathered.”
In a statement, SEGM co-founder Zhenya Abbruzzese said, “SEGM and Dr. Guyatt have had a longstanding but collegial debate about the role of child autonomy in gender medicine.” Nevertheless, the nonprofit’s collaboration with his team, she said, had been “grounded in mutual respect.” Expressing disappointment that the academics had yielded to activist pressure, Abbruzzese added: “Young people experiencing gender dysphoria deserve evidence-based care.”
Bringing Guyatt to heel is but the latest chapter in a history of campaigns to attack the reputations of academics who threaten trans activists’ ambitions where children are concerned. In one notable pile-on, Michael Bailey, a pioneering psychology professor at Northwestern University, saw his 2023 paper on “rapid-onset gender dysphoria” subjected to an avalanche of scorn from trans activists and activist-academics. They ultimately succeeded in getting the paper retracted due to what Bailey insisted was unwarranted censorship based on a mere pretext.
“I have some regrets in life, but my unwillingness to buckle under ideological pressure like Dr. Guyatt did isn’t one of them,” said Bailey, who republished his paper elsewhere. “Indeed, it’s one of the things I’m proudest of.” Such bravery remains rare, and is invaluable to defend academic freedom in a field in desperate need of better research.
The most rigorous academic analysis to date of the research backing puberty blockers and cross-sex hormones as treatments for gender-related
By: Benjamin Ryan
Published: Jan 23, 2025
The most rigorous academic analysis to date of the research backing puberty blockers and cross-sex hormones as treatments for gender-related distress in young people has found it has produced ‘very uncertain’ evidence.
A pair of major new analyses of research into providing gender-transition drugs to adolescents and young adults have indicated that a prevailing orthodoxy in the U.S. medical community — that such treatments are safe and effective for gender-distressed minors — is largely based on “very uncertain” scientific evidence.
The most rigorous such analyses of their kind to date, these new academic papers are the latest reports to cast doubt on the transgender movement’s battle, now on the defensive, to protect minors’ access to ultimately irreversible gender-transition treatments. The new analyses reach the damning conclusion that almost all the research assessing such treatments is decidedly unreliable at anticipating risks and benefits alike, thanks to consistently weak study designs that leave the door wide open for biased and unreliable results.
This sweeping finding echoes the four-year independent assessment of the field of pediatric gender medicine, called the Cass Review, that was commissioned by Britain’s National Health Service and published to great fanfare in April. The nearly 400-page report was anchored on the finding that the field was based on “remarkably weak evidence.”
These critical assessments of the controversial medical practices – which in recent years have been banned for minors in 24 states – stand in direct conflict with a nearly united front among American medical associations who endorse the prescribing of puberty blockers and cross-sex hormones for minors experiencing gender dysphoria, which is distress stemming from a conflict between an individual’s sex and gender identity. Prominent societies such as the American Academy of Pediatrics and the American Medical Association have touted such treatments as effective and even life saving – since, advocates claim, gender treatments prevent suicides.
Dr. Gordon Guyatt, a physician and professor at McMaster University in Ontario, effectively begs to differ, having found that there is no such clear-eyed certainty about the impacts of these treatments on young people. Known as the “godfather of evidence-based medicine,” Dr. Guyatt on Thursday published in the Archives of Disease in Childhood a pair of systematic review papers of pediatric gender medicine that are the first of their kind to pool study findings and conduct meta-analyses regarding particular outcomes among young people who have received these interventions.
One of the analyses examined studies on puberty blockers given to youth with gender dysphoria. The other looked at studies of cross-sex hormones to treat gender dysphoria in adolescents and young adults.
Dr. Guyatt and his colleagues concluded in both papers that there is “considerable uncertainty regarding the effects” of each intervention, given that the available research almost entirely yielded evidence of “very low certainty.” Regarding hormone treatment in particular, the authors concluded that “we cannot exclude the possibility of benefit or harm.” The only research finding they considered to be of “high certainty” was that a small percentage of people who started cross-sex hormones subsequently experienced cardiovascular health events.
“These papers come to the same conclusion as many other evidence syntheses — which is that we do not have a good evidence base to suggest that these treatments are effective,” said Dr. Ronny Cheung, a consultant general pediatrician in London. Dr. Cheung is the lead author of a recent peer-reviewed rebuttal to a white paper spearheaded by Yale University pediatrician Meredithe McNamara that sharply criticized the Cass Review.
The publication of these two papers from Dr. Guyatt is certain to provoke a chorus of disapproval among the many fierce defenders of pediatric gender medicine in America in particular, given their response to the Cass Review. That report has led the UK to ban puberty blockers outside of a promised clinical trial; and it has been broadly cited in litigation in the U.S. by opponents of these interventions for minors. Striking back, a coterie of academics such as Dr. McNamara has mobilized to cast doubt upon the report’s methodology and conclusions.
These champions of pediatric gender medicine have asserted in a string of recent publications, most of which have not been peer reviewed, that, for example, Cass has held these medical interventions to an exceptionally and impossibly high evidentiary standard. Pediatric treatments for all sorts of conditions, some of these champions have pointed out, are routinely based on low-certainty or very-low-certainty evidence (as opposed to moderate- or high-certainty evidence).
“It is true that many treatments in medicine have been, and are, used without a satisfactory evidence base. Sometimes this has led to belated evidence gathering in terms of clinical trials, which have subsequently shown benefit,” Dr. Cheung said in an email. “Equally, others have resulted in disastrous outcomes for patients despite the best intentions and biological plausibility. But it is a logical fallacy to say that because many treatments are given without sufficient evidence base, therefore any treatment without sufficient evidence base should be given.”
Moti Gorin, an associate professor of philosophy at Colorado State University said that given the “complexity and vulnerability” of pediatric gender dysphoria cases, “our standards should be very high.”
The Sun asked the lead authors of all of the recent Cass critiques to comment on Dr. Guyatt’s new papers. The sole respondent was Chris Noone, a lecturer in psychology at the University of Galloway, who argued that the new papers comment “on already identified limitations of research on these interventions related to sample size and comparison groups that are inevitable due to the small population, the impossibility of blinded comparison groups, and the ethics of preventing access to these interventions.”
As he has previously, Dr. Noone criticized the particular tool Dr. Guyatt’s team used to score the quality of the evidence, which he said, “given the aforementioned limitations will automatically lead to a judgment of very low certainty in the evidence.”
“The authors fail to articulate how a study of puberty blockers or hormone therapy for young people with gender dysphoria could ever produce evidence that is considered certain” by this tool, Dr. Noone said.
Dr. Guyatt was not available for comment.
The Trans Turning Point
The stakes have never been higher for the beleaguered and politicized medical field of pediatric gender medicine. The Supreme Court is set to rule, probably in June, on the constitutionality of state bans on gender treatments for minors in a case, first marshalled by the ACLU, in which the Biden Administration challenged Tennessee’s law. And while Donald Trump has yet to make good on his campaign promise to further restrict access to pediatric gender-transition treatment, within hours of his inauguration on Tuesday he signed a sweeping executive order attacking what his administration calls “gender ideology” throughout federal law.
This turning point in the history of transgender advocacy writ large follows a decade of dramatic growth in the population of young people diagnosed with gender dysphoria or otherwise identifying as trans, both in the United States and across the Western World. A research letter out of Harvard published in JAMA Pediatrics on Jan. 6 found about one in 1,000 privately insured 17-year-olds received cross-sex hormones between 2018 and 2022; and recent trends suggest this figure was likely considerably higher at the end of that period, especially among biological girls.
Another paper published Thursday in the Archives of Disease in Childhood reported that between 2011 and 2021, diagnoses of gender dysphoria among adolescents in primary care practices in England surged by more than 50-fold. Following a pattern well documented in the United States, diagnosis rates were similar between biological boys and girls until 2015, at which point they split, until the rate among natal girls was nearly twice that of boys in 2021. By that time, about one in 250 youths had such a diagnosis at age 18. Levels of anxiety, depression, and self-harm were high among this overall population, especially the girls.
The 2020s has seen the publication of a slew of systematic literature reviews – the gold standard of scientific evidence – assessing the quality of research and the resulting reliability of the evidence it produces among studies of gender-transition treatments for youths. All these papers have reached essentially the same conclusion: that the evidence backing prescribing gender-transition medications to minors is wanting and highly uncertain.
Such critical findings have led the health authorities in a swath of Northern and Western European nations, including the UK, to reclassify such treatments as experimental and to sharply restrict access to minors — or to at least consider pulling back on such access. In America, which lacks a comparable centralized health authority, medical-practice standards tend to be set by medical associations; and with the exception of one group representing plastic surgeons, those societies have overwhelmingly held firm in their support of such interventions.
The Evidence-Based Medicine Revolution Confronts Pediatric Gender Medicine
With Dr. Guyatt as one of its talismen, the field of evidence-based medicine emerged during the 1990s as a movement to hold scientific evidence to a higher standard. The goal was to assess the likelihood that the findings of research on any particular subject would actually bear out in clinical practice and that the recommendations based on that evidence were arrived upon in a rigorous and transparent way.
The field, for example, sought to confront the fact that, even if multiple studies reach similar findings, this might be due to the fact that they were all biased in a similar way and not because the results were valid. The type of analyses pioneered by Dr. Guyatt are meant to identify potential sources of bias in scientific research and to separate the evidentiary wheat from the chaff.
“Systematic review procedures block opportunities for cherry-picking studies that support only one side of an issue and help ensure all relevant studies are included,” said James Cantor, a Toronto psychologist and sex researcher who has often served as a paid expert hired by states to aid in defending their bans of this treatment. (Dr. McNamara has conversely often served as a paid expert for the other side. Both she and Dr. Cantor have been criticized for never having treated gender dysphoria in a minor.)
“The methods also work to ensure that all studies get evaluated with the same standards, minimizing opportunities to be more critical or favorable with studies on one side,” Dr. Cantor continued. “Because so many authors have been engaging in exactly these kinds of biased tactics when claiming what the science says about the effects of medicalized transition, the anti-bias methods of systematic reviews are even more important than usual.”
For the new paper on puberty blockers published Thursday, Dr. Guyatt and his colleagues scoured the relevant medical literature and settled on 10 key studies to analyze. Those papers, they concluded, “provided very low certainty evidence,” meaning the investigators had very little confidence the findings reflected the true impact of the treatment on gender dysphoria, global function (how well a person functions in daily life), depression, and bone mineral density.
Dr. Guyatt’s puberty blocker paper also highlighted a review paper out of England that recently called into question the veracity of the oft-repeated claim that the treatments are “fully reversible.”
The cross-sex hormone analysis examined 24 studies in which the average participant was younger than age 26 upon starting treatment (the average age ranged from age 15 to 25). These papers, the authors concluded, largely provided very low certainty evidence regarding such treatment’s impacts on gender dysphoria, global function, depression and bone mineral density changes. One study, which had an untreated comparison group, provided simply “low certainty” evidence—meaning the investigators had merely “limited confidence” it reflected the true effect of the treatment—that taking hormones was linked to a somewhat lower odds of having depression.
The only outcome the investigators considered to be of “high certainty,” meaning they were “very confident” it was close to reflecting the treatment’s true impact in clinical practice, was that there was a 4% rate of cardiovascular events among biological females 7 to 109 months after they started testosterone. That was due to a 2019 research letter by Dutch investigators that found that estrogen use in patients who were born male, with a median age of 30, was tied to a nearly doubled rate of stroke and a greater than fourfold higher rate of blood clots; and that testosterone use in biological females, with a median age of 23, was tied to an almost quadrupled heart attack rate.
Dr. Noone said that particular study could not isolate the impact of hormones on such outcomes, and that the heart disease events might have been driven by higher rates of tobacco smoking among trans people or the impacts of anti-trans stigma.
Overall, the design of the puberty blocker and cross-sex hormones literature reviews meant they could provide insights into the quality of life of youth on the drugs, the study authors concluded. But the analyses could not answer questions about the impacts of the drugs, such as whether quality of life or global function is better among those receiving the medications compared with others who were not.
The Battle Over Research Standards
Many advocates of pediatric gender medicine have insisted that randomized controlled trials, or RCTs, of gender-transition treatments for minors are not ethical—because, they argue, the benefits of these interventions are already so well established.
There is broader consensus among research experts that RCTs might not be feasible. For one, it would be impossible to blind such a study, since it soon becomes obvious to any young person whether they are experiencing physical changes indicative of being on hormones or off of blockers. And youth randomized to an untreated control group might be disinclined to remain in a study they saw as providing them no benefit.
All that said, Dr. Guyatt and his colleagues wrote in their new papers that to understand the impacts of both puberty blockers and cross-sex hormones on young people, “methodologically rigorous studies,” such as those that follow a population over time “are needed to produce higher certainty evidence.” They noted that this includes “RCTs (if ethical)” for blockers in particular.
Thus, the study authors did not insist on “high certainty” evidence, as many critics of the evidence-based approach to assessing pediatric gender medicine often attest, accurately or not, is the topline argument stemming from systematic literature reviews of the field; they called for higher certainty.
Similarly, despite a recent editorial in the New England Journal of Medicine suggesting that the Cass Review set the standard at the RCT level, the British report actually made a more general call for improved methodological rigor in studies of these treatments.
Dr. Guyatt’s papers further argued that physicians counseling young people about receiving these interventions have an obligation to communicate to these patients and their caregivers about the very low certainty of the supporting scientific evidence. Acknowledging the crucial role that patients’ so-called values and preferences play in such clinical decision-making, the investigators called upon the authors of clinical guidelines and policy makers to be transparent about “whose values they prioritize when developing treatment recommendations and policies.”
Supporters of minors’ access to these medications often claim that the rate of regret-based detransitioning — in which someone stops gender-transition drugs and reverts to identifying and presenting as their birth sex — among those who started treatment as minors is extremely low. The Cass Review, though, found that due to limited patient follow-up, the true detransitioning rate is unknown.
Approximately two dozen detransitioners have filed lawsuits against their care providers, often claiming to have suffered irreversible harms to their body. Many of these plaintiffs are represented by a Texas firm established by a quartet of former white-shoe attorneys who set up their practice for the sole purpose of representing detransitioners — a population that they anticipate will only grow given the recent surge in trans identification among adolescents.
The authors of the two new analyses found they could reach no conclusions about rates of regret, anxiety or pelvic pain tied to receiving puberty blockers or hormones. Nor could they reach any conclusions about whether cancer was connected to hormone use or whether puberty blockers were linked to the suicide death rate. The analysis on hormones referenced one two-year U.S. study, published in 2023, in which, among 315 persons who started cross-sex hormones between ages 12 and 20, two died by suicide. Dr. Guyatt’s team deemed this association based on very low certainty evidence.
Nor did these analyses provide any substantial insights into a key concern: fertility. Concerns that providing treatment for childhood gender dysphoria with blockers and hormones might cause infertility have motivated many critics of this medical field to call for a higher quality of evidence than might otherwise be acceptable for pediatric medical interventions.
Leor Sapir, a fellow at the Manhattan Institute who studies pediatric gender medicine, praised Dr. Guyatt’s new analyses as the most “methodologically rigorous systematic reviews” in this field to date. He said that a notable shortcoming of the papers was the limited information they provided about various potential harms of these treatments — a fault he attributed to the wider medical field.
“Gender clinics and clinicians are usually the ones who study medical interventions in this area,” Dr. Sapir said, “And they have little interest or incentive to conduct rigorous, longitudinal studies on the harms of the interventions they adamantly support.”
Following the Science
Dr. Guyatt’s papers are likely to impact ongoing litigation over pediatric gender medicine. Alabama’s attorney general, Steve Marshall, made that evident in a statement to the Sun, when he praised the new papers and said they confirmed “that states like Alabama are on firm footing in restricting these treatments for minors and by encouraging the medical community to finally follow the science itself.”
The papers did not, however, call for such bans, rather for better research. Some of the nation’s major pediatric gender care research hubs are in states that have passed such bans, which threaten to end their research entirely.
As Mr. Marshall’s scathing amicus brief to the Supreme Court for the case over Tennessee’s ban laid bare, records that the attorney general subpoenaed from the World Professional Association for Transgender Health, a prominent transgender medical-activist group, revealed that WPATH suppressed publication of systematic reviews it had commissioned from evidence-based medicine experts at Johns Hopkins University as it developed its 2022 revision to its widely referenced trans-care guidelines.
“It is no great mystery why WPATH acted the way it did,” said Mr. Marshall. In a nod to Dr. Guyatt’s advice for guidelines committees, Mr. Marshall continued: “As these latest systematic evidence reviews confirm, there is woefully insufficient evidence to support WPATH’s strong recommendation that kids be given puberty blockers, cross-sex hormones, and surgeries to treat their gender-related distress.”
Dr. Guyatt’s papers are likely to be attacked due to their funding source. The research was commissioned by the Society for Evidence-based Gender Medicine, or SEGM, which is a collective of physicians and researchers who are skeptical of the evidence supporting pediatric gender medicine and are regarded as an adversary by the transgender rights movement.
The Southern Poverty Law Center has gone so far as to brand SEGM a hate group that traffics in pseudoscience. (The SPLC has itself faced heavy criticism from the right in recent years for expanding its label of hate groups to apply broadly to religious conservatives and other groups that oppose liberal orthodoxy.) However, a three-day conference SEGM held in New York City in the fall of 2023 was almost entirely lacking in politics or any trace of prejudice or animus against transgender people. Instead, it offered a trenchant crash course in evidence-based medicine principles and their application to this field.
That said, SEGM’s critics assert that the organization leans on such intellectual principles as a mere pretext to sow doubt among the public and policymakers alike and, above all, to lend academic credibility to efforts to outright ban these interventions.
In an interview, SEGM cofounder Zhenya Abbruzzese, a health researcher, firmly denied any such political motivation. She further said that Dr. Guyatt’s team kept her organization “at arm’s length” throughout the work on the review papers, and, unlike the Johns Hopkins team’s ultimate arrangement with WPATH, the academic team had full right to publish regardless of the findings.
Speaking to the effort in modern medicine to treat gender dysphoria in young people with blockers and hormones, Ms. Abbruzzese said, “We are operating in the dark. But we don’t have to be.”
She pointed to the robust national health databases in many European nations, in particular in Scandinavia, and argued that researchers could reach at least moderately certain conclusions about the potential impacts of these treatments by conducting research based on those health records.
“It’s time to look at that data in a very rigorous way,” Ms. Abbruzzese said.
Researchers have already conducted such health-database analyses regarding gender transition surgery’s association with mental health outcomes in Swedish adults and cross-sex hormones’ link to suicide deaths in Finnish youths.
Both studies found the interventions were tied to no such benefits.
[ Archive: https://archive.today/GSsQP ]
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History will judge this as worse than thalidomide. It's been clear for a long time that there's no evidence supporting the effectiveness of these 'treatments.' The evidence in support is of poor quality, while the evidence against shows that these treatments are not only ineffective but also harmful. Unlike thalidomide, which was withdrawn very quickly, the present day scandal continues on despite everything we already know solely because of suicidal empathy.
An ugly lawsuit now in trial has exposed Boston Children's Hospital's 'reckless' and rushed diagnosis and treatment process for trans kids.
By: Benjamin Ryan
Published: Oct 31, 2024
Boston Children’s Hospital slashed the time slated for psychologists to assess and write a report on children seeking gender-transition treatment from 20 hours to under 3 hours, alarming experts.
The world-renowned Boston Children’s Hospital is being denounced by leading psychologists for drastically reducing the time it allocates for mental-health professionals to determine whether children identifying as transgender should receive gender-transition treatment. Shocked and dismayed by the hospital’s policy, these experts in pediatric-gender medicine have called the shortened assessment period woefully inadequate — considering the complexity of gender-related distress in minors and the fact that these medications are life-altering and, in the case of testosterone and estrogen, cause irreversible effects.
During the second half of the 2010s, leaders at the pediatric gender clinic at Boston Children’s first cut in half, and ultimately slashed by eightfold, the time they typically scheduled for in-house psychologists to assess gender-distressed children before determining whether they should be referred to endocrinologists to begin a treatment path that includes puberty blockers and cross-sex hormones.
By about 2018, the gender clinic’s assessment policy was to provide these minor-age patients only a one-hour appointment with a psychologist, plus one hour with that provider and their family. This is according to three staff psychologists and the clinic’s director.
“It’s shocking,” Laura Edwards-Leeper, a former Boston Children’s psychologist who helped found its gender clinic, told the Sun of the dramatic reduction in time allotted for such assessments.
This reported sea change in clinic policy came to light thanks to a lawsuit brought by a fired psychologist that is now being heard in Suffolk County Superior Court in Boston. Amy Tishelman, 68, has accused Boston Children’s Hospital of age- and gender-based discrimination and of retaliation. The hospital terminated her in 2021, alleging she violated a patient-privacy law; she had filed her initial discrimination suit against the institution the year prior.
Dr. Tishelman, who is widely recognized as a leader in pediatric gender medicine, on Thursday testified that when she began working for Boston Children’s gender clinic in 2013, administrators allotted her 20 hours, and sometimes longer, to assess whether a child should be referred for gender treatments; this included her time to write the report on the patient.
A few years into her tenure at the gender clinic, the hospital had cut that period to 10 hours, she said. Then, by early 2018, it had slashed the time again.
“I didn’t feel like that was doable at all,” Dr. Tishelman said from the stand. She denounced as “reckless” the clinic’s policy it adopted over six years ago of allotting just two hours of assessment-appointment time and a half hour for report writing.
Speaking to the complex calculus involved in considering whether gender-distressed adolescents should receive powerful medications to alter their puberty, Dr. Tishelman continued: “There’s a lot of things to think about in the long- and short-run. It’s not like taking an aspirin. It’s a big deal.”
That it has taken so many years for these specific policies at Boston Children’s to be laid bare lends weight, critics suggested to the Sun, to the persistent allegations that pediatric gender care, a controversial medical specialty, is lacking in transparency.
The associated political stakes are substantial. During the presidential campaign’s home stretch, President Tru.mp has relentlessly hammered Vice President Kamala Harris for her past support of taxpayer funded gender-transition treatments for prisoners, including detainees who are undocumented migrants. His campaign has funneled tens of millions of dollars into attack ads on this issue.
Dr. Tishelman alleged in court that her supervisor at Boston Children’s, Dr. Yee-Ming Chan, was threatened by her success and had long subjected her to sexist and ageist treatment. Dr. Chan, who denies these claims, is a pillar in the field of pediatric gender medicine in his own right. He is a co-principal investigator of an ongoing and multipronged $10 million National Institutes of Health–spon.sored research endeavor of the care transgender youth, including studies of the use of puberty blockers and cross-sex hormones to treat gender-related distress.
Republican members of Congress last week pledged to launch an investigation into the federal grant funding this study. They were inspired to do so after The New York Times reported that the research project’s leading investigator, Dr. Johanna Olson-Kennedy of Children’s Hospital Los Angeles, said that she had refrained, expressly for political reasons, from publishing the team’s study finding that puberty blockers were not tied to psychological benefits.
The Boston trial has also shone a harsh light on a substantial blind spot in pediatric gender medicine: the crucial question of how those who medically transition as minors fare as adults.
By stripping Dr. Tishelman of her right to see patients in the gender clinic in 2019, she and her attorney alleged in court, Boston Children’s compromised her vital research into the care of transgender children. By firing her outright two years later, she said, the hospital terminated, among other research, her effort to establish a comprehensive database of all the patients the gender clinic had ever seen and to follow up with those who had reached adulthood.
“We were the first clinic to see transgender kids in the United States, and we don’t know whatever happened to them and how they’re doing,” Dr. Tishelman testified about the hundreds of former patients who have aged out of the clinic’s care.
“It’s damning that an institution like that, which has all those esteemed affiliations with major universities, would put the kibosh on an area of research that’s so desperately needed and would have informed their administrative decisions had they allowed it,” Erica Anderson, a psychologist and former head of the U.S. division of the World Professional Association for Transgender Health, or WPATH, told the Sun.
Boston Children’s is most prominently affiliated with Harvard Medical School.
Dr. Anderson, who is transgender, said that the assessment-related testimony from multiple Boston Children’s employees in Dr. Tishelman’s trial — who gave no indication that the drastically shortened assessment time is anything but a long-standing clinic policy — suggested a “fall from grace” for the prestigious hospital. The institution, she said, has “capitulated to the medicalization of children in a way that is reckless.”
“When people like Amy Tishelman are forced to draw a line in the sand and say, ‘no,’ and institutions come down hard on someone like her, we’re in deep trouble in America,” Dr. Anderson said.
A leader in the field, a challenge to that reputation
The gender clinic housed at Boston Children’s, called the Gender Multispecialty Service, or GeMS, is a pioneer and considered to be among the pre-eminent clinics of its kind in the United States. Consequently, the news that GeMS will approve children for gender-transition treatment at a pace multiple leading gender-medicine psychologists told the Sun was alarmingly hasty will likely deal a blow not only to the hospital’s reputation, but to this controversial and besieged medical field as a whole.
Opponents and skeptics of prescribing puberty blockers and cross-sex hormones to treat gender-related distress in minors frequently characterize the nation’s pediatric gender clinics as engaging in sloppy, rushed care. These critics, who include many Republican lawmakers as well as a few vocal insiders like Dr. Anderson, often assert that doctors routinely place vulnerable adolescents suffering from myriad mental health problems on powerful, life-altering drugs without engaging in proper due diligence.
Given the nation’s fractured health care system and a prevailing lack of routine patient-data collection in this field, as well as an evident reticence by gender-medicine researchers to publish unflattering research findings, comprehensive information about actual assessment practices at these clinics has remained fairly elusive.
The expositions that have emerged at Dr. Tishelman’s trial consequently shed crucial light onto the practices of a medical field that has become increasingly insular and secretive as it has faced mounting political and public scrutiny, lawsuits and, for Boston Children’s in particular, even threats of violence.
The hospital sustained waves of bomb threats in 2022 after the influential conservative social-media account LibsOfTikTok focused its criticism on the Boston gender clinic and others like it. The account, run by Chaya Raichik, circulated videos that Boston Children’s had published, and ultimately deleted, advertising its gender-transition services, including surgeries it indciated it would perform on minors.
Evidently concerned, at least in part, by the potential for further threats of violence, attorneys for Boston Children’s have sought to keep shielded from public view allegations about GeMS’s practices that were included in exhibits Dr. Tishelman submitted for her lawsuit. In an October 2023 filing successfully requesting that the judge overseeing the case seal portions of those exhibits the attorneys wrote:
“Public disclosure of these allegations will add fuel to an already highly charged public debate over the care of gender diverse youth and could cause serious, irreversible harm to the Hospital and the practitioners who Plaintiff now, for the first time, accuses of providing substandard care to this already at-risk population.” The attorneys further asserted: “GeMS practitioners provide individualized, safe, and affirmative care.”
A representative for Boston Children’s declined to answer questions from the Sun, saying the hospital could not comment on pending litigation.
How Boston Children’s began the U.S. pediatric gender-medicine revolution
In 2007, Boston Children’s became the first U.S. clinic to import a pediatric gender-transition treatment protocol pioneered by researchers in the Netherlands. The Dutch model, as it’s known, observed strict criteria that only prescribed puberty blockers and cross-sex hormones to minors who had consistent cross-sex identification from early childhood, supportive parents, and no major other psychiatric problems. The model also discouraged prepubescent social transitions.
According to a 2014 paper regarding 55 of the first Dutch youths to receive gender-transition treatment and surgeries under the protocol, their outcomes by young adulthood were generally favorable. The notable exception was one participant who died from complications from a vaginoplasty.
During the transformative decade since then, diagnoses of gender dysphoria — meaning distress stemming from a misalignment between a person’s biological sex and their gender identity — in young people have soared across the Western world. In response, scores of gender clinics nationwide have opened, following Boston Children’s lead.
Concurrently, the profile of the typical patient presenting at pediatric gender clinics has shifted profoundly from the makeup of the original Dutch cohort. Today’s gender-dysphoric minors are more likely to be natal females and to only express gender dysphoria after puberty’s onset. They also have a higher rate of other psychiatric conditions and autism.
In tandem, U.S. gender-medicine practitioners have become known worldwide for their particularly eager abandonment of the Dutch model’s guardrails. In their place, clinics such as Boston Children’s have adopted a philosophy known as gender-affirming care.
The gender-affirmative ethos has been propagated and popularized in particular by a policy statement published by the American Academy of Pediatrics in 2018. The statement encourages care providers to observe deference to a child’s self-perception of their gender and essentially let the child take much of the lead in their own care. The document is now the subject of a medical-malpractice lawsuit and a recent probing letter from Republican state attorneys general.
Recent analyses of national medical-claims data provide at least some sense of how common pediatric gender care has become. The nonprofit Do No Harm recently conservatively estimated that at least 14,000 U.S. minors received gender-transition medications, surgeries, or both between 2019 and 2023. And the Manhattan Institute estimated, also conservatively, that 5,300 to 6,300 minors—as young as 12 years old—received gender-transition mastectomies between 2017 and 2023.
Boston Children’s, Do Not Harm found, provided such services to at least 300 children, accounting for nearly half the cases that the analysis identified in Massachusetts.
According to GeMS’s website, the clinic has cared for more than 1,000 families. The site states: “We believe in a gender-affirmative model of care, which supports transgender and gender diverse youth in the gender in which they identify. This is a standard of care grounded in scientific evidence, demonstrating its benefits to the health and well-being of transgender and gender diverse youth.”
Recent systematic literature reviews—the gold standard of scientific evidence—have cast serious doubt on assertions that the evidence base behind pediatric gender-transition treatment is robust and reliable. These reviews have all found that such medical interventions are based on shaky and uncertain research findings.
The broad adoption of the gender-affirming care method and the concurrent surge in gender-transition treatment prescriptions have helped fuel a furious backlash among state-house Republicans. Since 2021, 26 states have passed laws banning pediatric gender-transition treatment; all but two of them ban transition surgeries for minors as well. In December, the Supreme Court will hear oral arguments over whether Tennessee’s treatment ban violates the Constitution.
Gary Click, a Republican state representative from Ohio, marshaled that state’s ban into law. In an email to the Sun, he responded to news from Dr. Tishelman’s trial, specifically that Boston Children’s assesses gender-dysphoric minors in just two hours of appointment time, by criticizing the pediatric gender-transition treatment advocates with whom he has clashed.
“While I consistently advocated for mental-health over medical interventions, I was frequently and falsely accused of denying psychological care,” Mr. Click said of such advocates. “I’ve since discovered they are usually guilty of what they accuse us of doing. Now it appears that they are in a rush to medicate children before they have a chance to heal emotionally and choose a normal life.”
An employment lawsuit affords a rare view inside a top gender clinic
Dr. Tishelman, who is an expert in child maltreatment and trauma, worked at Boston Children’s for nearly three decades. In 2013, she was appointed the director of clinical research at GeMS. Prior to her termination, she was a senior attending psychologist at the hospital and an assistant professor at Harvard Medical School.
In addition to her research duties, Dr. Tishelman spent a relatively small portion of her overall schedule conducting the psychological assessments of gender-dysphoric patients who were potential candidates for gender-transition treatment.
WPATH guidelines advise that gender clinics conduct a comprehensive assessment of such pediatric patients prior to prescribing them gender-transition drugs.
Today, Dr. Tishelman is a research associate professor in psychology at Boston College. Her 2021 amended legal complaint, filed after she was fired in March of that year, charts what it claims was a fraught relationship between her and the Boston Children’s pediatric endocrinologist Dr. Yee-Ming Chan. Her complaint states that Dr. Chan, who is over a decade her junior, became her supervisor at GeMS in 2014.
Dr. Chan repeatedly disputed in his testimony on Monday that he was indeed her official supervisor at the gender clinic.
The legal complaint alleges that Dr. Chan subjected Dr. Tishelman to “a ceaseless sexist and ageist campaign of denigrations, accusations and recriminations” that created a hostile work environment and was driven by his “professional jealousy.”
Dawn Solowey, an attorney for Boston Children’s of the law firm Seyfarth Shaw, asserted during her opening statement on Oct. 21 that Dr. Chan sought to foster a productive and copacetic working relationship with Dr. Tishelman. During his testimony, he denied Dr. Tishelman’s accusations of mistreatment.
Both Psychologist Kerry McGregor, who is now the associate director of GeMS, and Francie Mandel, a senior clinical social worker supervisor at the clinic, testified favorably about Dr. Chan’s character and professionalism and cast those qualities of Dr. Tishelman in a negative light.
There remain several days of additional testimony in the trial that might flesh out the details of all the contrasting accounts.
Dr. Tishelman testified that other GeMS employees reacted with jealousy to the news in late 2017 of her appointment by WPATH as the lead author of the revision to its guidelines on care for prepubescent children with gender dysphoria. However, many professionals throughout the national field congratulated her, she said.
Soon after the WPATH appointment, Dr. Tishelman testified, GeMS doubled her clinical work, demanding that she see far more gender dysphoric patients than her schedule permitted. Others testified that this shift was unrelated to the news regarding WPATH.
“When I started, there were 20 hours,” Dr. Tishelman said of the time allotted for patient assessments. “And now they were asking me to do them in two-and-a-half hours.”
The assessments, she said, were meant to address a litany of complex needs and concerns. The original 20 hours included the time for Dr. Tishelman to speak with a gender-distressed child and their family; conduct scoring of major mental-health and neurodivergence markers; assess for suicidality; and determine the family’s concerns about infertility, which is a major risk of pediatric gender-transition treatment. Additionally, she might secure permission to confer with the patient’s outside therapist or school counselor. The time allotted also factored in her effort to write a detailed report on whether the child was a proper gender-transition treatment candidate and what other types of support they might need.
“Kids can be confused about what they want to do,” she said on the stand. “It’s a collaborative process to try to work with kids and their families to try to figure out what’s best for them, knowing the benefits and risks—being informed about the choices.”
Dr. Tishelman testified that by early 2018, GeMS administrators eliminated from the assessments a screening measure for autism. She alleged that despite what she characterized as the degradation of the assessments’ quality by that time, GeMS would include in various reports about the clinic’s work that its staffers followed WPATH’s trans-care guidelines.
“Shortening evaluations” at GeMS “eventually became a big concern” among her research collaborators nationwide, Dr. Tishelman testified. “People would complain to me about my protocol from outside,” she said in reference to those national colleagues.
Dr. Tishelman specified that Dr. Robert Garofalo, a leading pediatrician at the gender clinic at Lurie Children’s Hospital in Chicago, expressed a concern to her at around this time regarding GeMS excluding from the assessments a measure of family acceptance and support of transgender patients. Along with Dr. Chan, Dr. Garofalo is a co-principal investigator on the long-running NIH-funded study of which Dr. Olson-Kennedy is the research lead.
“I would try to tell people that I was not in charge of the protocol,” Dr. Tishelman testified.
Dr. Garofalo responded to an email seeking comment by asserting that the Sun’s initial characterization of Dr. Tishelman’s testimony about him was incorrect. But after the Sun then clarified her words about him, he did not respond further.
Dr. Edwards-Leeper was a coauthor under Dr. Tishelman of the WPATH guidelines chapter revision on prepubescent children and also co wrote the accompanying adolescent chapter. Having left GeMS in 2011, Dr. Edwards-Leeper now practices in Ohio. She reported that she faced similar pressure to assess patients faster from an employer in the interim.
She refused.
“There was no possible way I could cut corners,” she said. Today, in private practice, she directly assesses gender-dysphoric adolescents and their parents for at least 10 hours and ultimately writes a 20- to 30-page report on them.
Dr. Edwards-Leeper, who was on the team that first imported the Dutch protocol to Boston Children’s, told the Sun that she only relatively recently learned that GeMS had progressively slashed its assessment time period during the late 2010s.
“When Amy first shared that with me, I was just in disbelief,” said Dr. Edwards-Leeper, expressing concern that the system of patient oversight she had helped establish at GeMS — one in which she said that, as Dr. Tishelman testified, psychologists spent about 20 hours on the assessment process all told and produced a 15- to 20-page report — had been compromised.
On Tuesday, Dr. McGregor testified that the clinic had allotted four hours of “face-to-face time” with patients for assessments when she started at GeMS in 2016 and ultimately cut this to two hours. The day prior, Dr. Jeremi Carswell, director of GeMS, also testified that the assessment appointment time had been cut from four hours to two hours.
“My understanding is that some were unhappy about it,” Dr. McGregor said about the time reduction, specifying Dr. Tishelman and GeMS psychologist Peter Hunt in particular. “I thought it was appropriate. But some people wished they’d had that time.”
Further asked by a Boston Children’s attorney about why the assessment time was reduced, Dr. McGregor said: “I think that four hours was too much time. If you ever try and get an adolescent to pay attention to you for four hours straight, it’s a little bit difficult. And also we were able to get all the information in much less time. So, in order to see our growing patient population, it made sense to make that time more efficient.”
Dr. McGregor, who said she spent about 15 to 45 minutes writing her assessment reports, with the aid of a template she created, continued: “And we also could always ask for more time if we needed to. So I’ve met for a second session with patients. It’s pretty rare, but I do it if I need it.”
Asked if two hours was typically sufficient to perform what the attorney called “a hormone-readiness assessment,” Dr. McGregor replied that it was. And asked for greater specifics about occasions when she said this was not sufficient time, she said, “Very rarely, but usually if someone has extreme social anxiety, they don’t want to talk, it takes a while to warm them up, maybe they’re on the autism spectrum, things like that, it might make sense to have a second session.”
Dr. Tishelman’s attorney, Patrick Hannon, of Hartley Michon Robb Hannon, asked Dr. McGregor about the videos that GeMS put out advertising their services. She referred to one in which she suggested that, as she recalled in her testimony, “a lot of parents share that some of their children seem to know seemingly from the womb as if they come out kind of knowing who they are,” meaning transgender.
“There’s no scientific research that would support the assertion that kids know whether they’re transgender as soon as they come out of the womb, right?” Mr. Hannon asked Dr. McGregor.
“I don’t know how we would do that scientific research, so no,” she replied.
What is typical practice in this field?
It is evident that many of the nation’s pediatric gender clinics do engage in lengthy and circumspect assessments of gender-dysphoric minors seeking puberty blockers. But WPATH’s recommendation on this measure notwithstanding, it is also apparent that there is no uniformly upheld standard across this medical field and that assessment times and thoroughness vary dramatically.
Some American mental-health providers, for example, advertise that they will write a letter recommending a gender-dysphoric child for puberty blockers after only a single visit.
Dr. Edwards-Leeper has defended the value of robust assessments in the face of a burgeoning movement across the pediatric gender medicine field to question their utility.
The most comprehensive data set detailing assessment times comes not from America, but from Britain. A major analysis of pediatric gender medicine, called the Cass Review, that was published in April included information from an audit of discharge data regarding some 3,300 patients cared for by England’s pediatric gender clinic, known as GIDS.
The children from this cohort who were ultimately referred to endocrinology received the go-ahead after an average of just under seven assessment appointments. However, a substantial proportion of these children were referred after only three or four assessment appointments.
Anna Hutchison, a psychologist who worked for GIDS between 2013 and 2017, reflected on the prospect of being asked to assess a child and their family in only two appointments, as became the practice at GeMS in 2018. “What can you realistically achieve in that time?” Dr. Hutchinson said.
Dr. Hutchinson ultimately publicly protested policies at GIDS that she said resulted in incautious, unethical care. In an interview, she conjectured that the Boston clinic might have been under mounting demands similar to those that, across the Atlantic, caused the inadequately resourced GIDS to buckle. As the population of gender-dysphoric British children seeking care swelled, Dr. Hutchinson recalled, systemic pressure pushed her and her colleagues to spend less time assessing each child — even as the rate of other psychiatric conditions among the patients steadily increased.
“There are risks in changing what we do clinically based only on resources,” said Dr. Hutchinson. Referring to the increasing demand for services from increasingly troubled children, she said, “Because numbers are going up, complexity is going up, and the amount of time per patient her family goes down.”
“We essentially became an assessment and medication service,” she said of GIDS during her tenure.
Ms. Solowey, the attorney for Boston Children’s, suggested in court last week that GeMS also could not keep up with demand, saying that the clinic “had a really long waiting list.”
Ms. Mandel testified that the reduction, six years back, in appointment hours allotted for individual patient assessments at GeMS was driven not by clinical factors but by billing-related concerns.
As for insights into American practices, in October 2022, Reuters published an investigation of pediatric gender clinics in which it reported: “Seven of the clinics said that if they don’t see any red flags and the child and parents are in agreement, they are comfortable prescribing puberty blockers or hormones based on the first visit, depending on the age of the child.”
Nearly two dozen medical-malpractice lawsuits have been filed by detransitioners – people who medically transitioned and then regretted it, stopping treatment and reverting to identifying as their birth sex – against health and mental health providers over the past two years. Central to many of those suits are claims that minors or young adults suffering from multiple other psychiatric conditions were prescribed gender-transition treatment for dysphoria after only a cursory assessment that failed to meet the WPATH standard.
Jordan Campbell, a partner at Campbell Miller Payne, a Dallas firm that represents many of these plaintiffs, told the Sun: “Dr. Tishelman’s testimony squares with what we see and hear from every single one of our clients: a general sense to rush patients into life-altering medicalization with very little — frequently even less than two hours — assessment, if any.”
In Feb. 2023, Jamie Reed famously blew the whistle on her employer, The Washington University Transgender Center at St. Louis Children’s Hospital, where she had been a case manager. Ms. Reed has accused the since-shuttered clinic of shirking its responsibility to provide comprehensive aid to a population of vulnerable children with very complex needs. (An internal university investigation found the clinic followed “appropriate policies and procedures according to the accepted standards of care.”)
“I long suspected that the sloppy care Wash U. provided would be found across the country,” Ms. Reed told the Sun. During her time at the St. Louis clinic, she said, “I was often unable to refer patients to high-quality psychological assessment, and our clinicians were also limited to scheduling only two sessions to complete an assessment—matching Dr. Tishelman’s account.”
Dr. Tishelman’s downfall
Attorneys for Boston Children’s have asserted in court that the hospital stripped Dr. Tishelman of permission to see GeMS patients in 2019 as a consequence of her chronic delinquency in turning in her patient reports; Ms. Mandel confirmed in her testimony that some reports were late. At that time five years ago, Dr. Tishelman testified, she had six delinquent reports.
The hospital claims that it fired Dr. Tishelman outright in 2021 for violating federal patient privacy laws by viewing, without authorization, records of hundreds of patients not under her care. The hospital alleged that she secretly accessed those files in 2019 in hopes of defending herself by identifying other delinquent psychologist colleagues.
Dr. Tishelman testified that the deadlines for her reports were deliberately unreasonable, given how GeMS administrators had burdened her with an excessive workload. She asserted that the clinic singled her out and “set me up to fail.”
Dr. Edwards-Leeper and Erica Anderson were among the dozens of major figures in pediatric gender medicine who signed a letter of protest to Boston Children’s over Dr. Tishelman’s firing.
In his opening statement, Mr. Hannon said that the patient-privacy-related infraction was a “tru.mped up” pretext for Dr. Tishelman’s termination. Dr. Tishelman ultimately testified that the GeMS patient population was considered communal among the staff psychologists and that it was common practice to discuss one another’s cases and review related medical records at staff meetings. Dr. Tishelman said that Dr. Chan knew in mid-2019 that she had recently reviewed other clinic psychologists’ reports and that he made no objection at the time.
Dr. Tishelman said Dr. Chan confirmed to her during that meeting that the other psychologist at GeMS she had identified as delinquent – Kerry McGregor –was making recommendations regarding gender-transition treatment for children despite omitting key information meant to be in the reports.
“You can’t really write the report without using all the information we’re gathering to put together to understand these people,” Dr. Tishelman testified. “Otherwise why would we even collect that information in the first place?”
Dr. McGregor testified that records indicated her reports were not actually delinquent. She said that at that time there were “some addended scores that I had not placed for the assessment report” – an oversight that she said she quickly rectified.
She further testified that she was alarmed when she learned in 2019 that Dr. Tishelman had accessed her patient records; the following year, she determined that this included files pertaining to over 200 children. Dr. McGregor recalled that Dr. Carswell relayed to her in mid-2019 that the legal department at Boston Children’s found there were some legitimate reasons for Dr. Tishelman to have accessed those records and that her having done so was not cause for concern.
Two years later, however, Dr. Tishelman was terminated from the clinic.
What NYT reported about Johanna Olson-Kennedy sitting on her null findings on puberty blockers is but one such story in a field in which man
By: Benjamin Ryan
Published: Oct 24, 2024
[ That’s a quote from a talk that pediatric gender medicine doctor Johanna Olson-Kennedy gave in which she was dismissing concerns about young people potentially regretting getting double mastectomies for a gender transition. ]
Some of the biggest names in the pediatric gender medicine field are part of an entrenched global trend in which they prioritize the transgender advocacy mission over honest and direct science. They hide inconvenient research findings. And they seek to prevent other researchers from even asking questions that might yield inconvenient answers. Supporting them is a cabal of activists and LGBTQ nonprofits standing at the ready to bully and cancel any scientists or journalists who might bring to light any of the more questionable aspects of pediatric gender medicine.
This pattern is not just limited to Children’s Hospital Los Angeles’ Dr. Johanna Olson-Kennedy. If you haven’t already heard, according to reporting in The New York Times, this major leader in the pediatric gender medicine field has been sitting on null findings from her National Institutes of Health–funded study of puberty blockers for gender dysphoric children because, she said, publishing them would prove politically inexpedient. (I wrote about an undercover video of her talking about mastectomies here.)
Where have we heard this story before?
Let’s take a trip across the pond to the British National Health Service’s now-shuttered pediatric gender clinic, GIDS. (I encourage you to read all about this troubled clinic in Hannah Barnes’ book Time to Think. Make sure to get the new 2024 U.S. paperback, which has a vital new epilogue.) After it was founded in 2011, GIDS’s leaders sought to recreate the findings of the original Dutch protocol that was first cultivated in the mid-1990s and that ultimately gave rise to the global pediatric gender-transition treatment movement during the 2000s and 2010s.
But the British team failed. They did not find a substantial benefit from providing puberty blockers to gender dysphoric children by following the Dutch protocol. So did these researchers alert the world to their troublesome findings? Did they send a word of caution to a field that by then was circumnavigating the globe, setting up what would soon be hundreds of pediatric gender-clinic outposts?
No, they kept their failure secret.
It wasn’t until Oxford sociologist Michael Biggs became suspicious and ultimately rooted out the truth that the GIDS clinicians finally owned up and published their failed study.
Also in England, the NHS’s Cass Review, which was published in April after a four-year effort to assess pediatric gender medicine at home and worldwide, sought to assess the long-term outcomes of the wider population of former GIDS patients. But the adult NHS gender clinics refused to share their de-identified data on those now-adult patients, providing only specious reasons for their refusal.
Now it seems as if the NHS will ultimately force them to do so. But for now, the world is poorer for not having that data. Because this entire field is compromised by a woeful lack of long-term data, in particular about the more recent cohorts of gender-dysphoric adolescents who have undergone gender-transition treatment, and whose profiles are vastly different from those kids who entered the original Dutch study.
After the Cass Review came out, activists went into overdrive to tell wild falsehoods about it, as I reported at the time. Hilary Cass, the pediatrician lead author of the report, was appalled, and told a reporter that those activists were harming children.
A flood of false claims about England's Cass Review has coursed across social media and the press and among activists and academics. If only
Even when fact checked, Erin Reed, who has a popular Substack and X account, has repeatedly made demonstrably false claims about England's C
There are also plenty of examples of academics being discouraged from even asking research questions that might lead to an answer that would prove inconvenient for the pediatric gender medicine movement. Take, for example, the trio starting a long-term study to assess whether rapid-onset gender dysphoria is a true phenomenon. These three seasoned investigators have had to self-fund their research and are subject to persistent derision and scorn by trans activists for daring to ask difficult questions about this medical field and about the reasons for the recent surge in trans identification in natal girl adolescents in particular.
Branded as gender heretics by the pediatric gender-medicine establishment and transgender-rights activists, Michael Bailey, Dr. Lisa Littman
One of those three investigators, physician-researcher Dr. Lisa Littman, spoke to me for my article on The Trans Tipping Point in the New York Post. She said of the activists who attack her: “It’s as if their loyalty is to the transition interventions and not to the long-term health and well-being of transgender-identified young people.”
Here’s another example. When UCL neuropsychologist Sallie Baxendale sought to obtain peer review for her review paper about what scientists know—and don’t know—about the neuropsychiatric impacts of puberty blockers, here was what happened, according to what she wrote in Unherd:
None of the reviewers identified any studies that I had missed that demonstrated safe and reversible impacts of puberty blockers on cognitive development, or presented any evidence contrary to my conclusions that the work just hasn’t been done. However, one suggested the evidence may be out there, it just hadn’t been published. They suggested that I trawl through non-peer reviewed conference presentations to look for unpublished studies that might tell a more positive story. The reviewer appeared to be under the naïve apprehension that studies proving that puberty blockers were safe and effective would have difficulty being published. The very low quality of studies in this field, and the positive spin on any results reported by gender clinicians suggest that this is unlikely to be the case.
Another reviewer expressed concerns that publishing the conclusions from these studies risked stigmatising an already stigmatised group. A third suggested that I should focus on the positive things that puberty blockers could do, while a fourth suggested there was no point in publishing a review when there wasn’t enough literature to review. Another sought to diminish an entire field of neuroscience that has established puberty as a critical period of brain development as “my view”.
Dr. Baxendale ultimately published her vital review paper, which concluded: “Critical questions remain unanswered regarding the nature, extent and permanence of any arrested development of cognitive function associated with puberty blockers. The impact of puberal suppression on measures of neuropsychological function is an urgent research priority.”
Meanwhile, the American Academy of Pediatrics has assured the public in its 2018 policy statement on the gender-affirming care method that puberty blockers are “reversible.” Twenty Republican attorneys general recently sent a stern, probing letter to the AAP, suggesting that that claim, which they assert is false, violates consumer protection laws. A lawsuit is likely imminent. The AAP is already being sued by a detransitioner over the statement. The original legal complaint lambasts the AAP for never responding to Canadian sex researcher James Cantor’s scathing fact check and critique he published of the policy statement in 2019.
Personally, I don’t think the claim that puberty blockers are reversible is definitively false, given what science is able to tell us at this time. But on the flip side, we also know that it is not definitely true either. As Dr. Baxendale’s paper demonstrates, there remain too many substantive and unanswered questions about how using drugs that throw vital human development processes out of synch might impact a young person, possibly for the rest of their lives.
The AAP announced in August 2023 that it was going to conduct a systematic literature review of the evidence behind pediatric gender medicine—and then never said another word about it. The authors of such reviews are expected to publish their methodology in advance, and the there is no sign that the AAP has done so.
Then there’s the World Professional Association for Transgender Health, or WPATH, which as the Alabama attorney general’s subpoenas have revealed and Jesse Singal reported for The Economist in June, suppressed systematic literature reviews about this field that it commissioned from Johns Hopkins. And after a Biden Health official and the AAP strong armed WPATH into removing the age restrictions on gender-transition treatment and surgeries in the update to its trans-care guidelines in 2022, WPATH president Dr. Marci Bowers coordinated for the leadership to lie about why they had done so. All of this is detailed in scathing, unsparing detail in the Alabama AG’s amicus brief to the Supreme Court, which argues that the court should uphold Tennessee’s law banning pediatric gender-transition treatment.
And in the wake of today’s news about Dr. Olson-Kennedy, we have an example of yet another front in this battle over pediatric medicine: the sheer denial and deflection coming from transgender activist Ari Drennen of Media Matters and the LGBTQ “media watchdog” GLAAD. As you can see from the tweet below, all they could do in the face of such a damning report was deflect.
This makes me wonder: What exactly is GLAAD’s endgame? This is the same nonprofit that had the temerity to condescend to the New York Times last year and falsely claim that the “science is settled” on pediatric medicine with their protest truck they drove around the Times building in Midtown Manhattan.
The science is, of course, not settled. No science is. It is always evolving, in particular in this tempestuous and troubled field of pediatric gender medicine. And there are many people in this wider movement who are seeking to suppress the full, ever-changing truth from coming to light.
At the center of this story is a burgeoning population of very troubled children. They are owed the best science possible. They are owed the truth, whatever that might be.
==
I previously posted about Olsen-Kennedy's tone-deaf endorsement of medical mutilation.
Imagine a medical study of a cancer treatment that was found to be ineffective, which was then covered up. Why would a report about that coverup need to quote people who had had cancer? These fanatics think we're stupid.
People wonder why the trust in our institutions is so low. It's because they keep producing this kind of fraud, which isn't science any more than Intelligent Design is science.
When the devoutly Christian John Templeton Foundation funded a study on intercessory prayer, they were forced to publish it, even though it found that it was ineffective. Or worse.
Intercessory prayer is widely believed to influence recovery from illness, but claims of benefits are not supported by well-controlled clini
Conclusions
Intercessory prayer itself had no effect on complication-free recovery from CABG, but certainty of receiving intercessory prayer was associated with a higher incidence of complications.
These genderists are doing religious proselytization.
The findings of a comprehensive analysis of insurance-claims data by the advocacy nonprofit Do No Harm.
By: Benjamin Ryan
Published: Oct 10, 2024
Medicalized gender transitions for minors were rapidly becoming more common in the United States until state bans of such medical interventions started to go into effect. Even in blue states where these medical practices remain legal, quite a few states saw a downturn in 2023, including in California and New York.
At least 14,000 minors underwent gender-transition treatment, surgeries, or both between 2019 and last year. This five-year tally is a conservative estimate, meaning that the true figure is likely higher, if not quite a bit higher. The figure is the product of a new analysis of national insurance-claims data that was released on Tuesday by Do No Harm.
This medical advocacy nonprofit is fervently opposed to minors accessing puberty blockers, cross-sex hormones, and gender-transition surgeries to treat gender dysphoria. Consequently, Do Not Harm’s word choice when describing these medical practices may strike some people as incendiary and even offensive.
“We feel very strongly that the science behind using these treatments in children is extraordinarily flawed and suggests that children are being harmed,” said the chair of Do No Harm’s board, Dr. Stanley Goldfarb, in a press briefing on Monday.
Do No Harm has published the findings of their medical-claims-data analysis in a comprehensive website—DoesMyHospitalTransitionKids.com—that allows users to investigate pediatric gender-transition and surgery data by state and by individual institutions within each state.
Main Findings in the 2019 to 2023 Medical-Claims Data:
13,994 unique minors received gender-transition surgeries, treatment, or both.
5,747 minors received gender-transition surgeries.
8,579 minors received puberty blockers, cross-sex hormones, or both (the analysis did not disaggregate to show how many minors received each type of medication). Between them, these minors were written 62,682 prescriptions.
Health care providers billed $119,791,202 for all these patients. The analysis did not reveal the dollar figure of how much these providers were actually reimbursed, mind you; that figure could be at least somewhat smaller.
The Williams Institute at UCLA estimates that 300,000 Americans age 13 to 17 identity as transgender. In April, the World Professional Association of Transgender Health (WPATH) argued that the majority of such minors would do best to undergo a medicalized gender transition. Consequently, from WPATH’s perspective, 14,000 minors receiving such a medical intervention over a five-year period is equivalent to only about 10 percent of the target population. However, on Tuesday, the Centers for Disease Control reported that 3.3 percent of high school students identified as transgender, compared with 1.4 percent according to the Williams Institute. It is difficult to discern whether this difference is a result of differences in survey methods, a rapid increase in youth trans identification, or both.
The math-minded among you may notice that there appears to be little overlap between the group that received surgeries and the group that received medication treatment, given that the sum of the two groups is 14,326; that is only 332 greater than the total number of minors who received either type of intervention. This defies logic, since presumably the vast majority of minors who undergo such surgeries are already taking cross-sex hormones.
This apparent lack of overlap between the two groups is a product of the analysis’ conservative methodology. The authors of the report only counted a cross-sex hormone prescription if it was written a maximum of 90 days following the entry into a patient’s medical file of a gender-dysphoria-related diagnosis code. Consequently, there may have been any number of cross-sex hormone prescriptions that the analysis did not include in its tally because too much time passed between the recording of a gender dysphoria-related diagnosis and the prescription of hormones.
“We have a very high level of confidence that what you are seeing here is directly related to sex-change treatments,” Michelle Havrilla, director of Do No Harm’s program to shield children from gender-transition treatment, said during Monday’s press briefing.
The Do No Harm analysis is also limited by the fact that its authors could not access medical-claims data regarding minor patients who either saw their care processed through internal Veterans Affairs claims, paid out of pocket, received charity care, or were cared for by Kaiser Permanente (which cares for a wide swath of patients across the West Coast in particular).
“What we’re really showing you today is a floor or a very conservative estimate of what’s happening throughout the country,” said Ms. Havrilla.
The Picture of Pediatric Gender-Transition Treatment Comes Into Sharper Focus
Do No Harm’s surgery figures are in the general ballpark of estimates put out by Leor Sapir of the Manhattan Institute in August. Dr. Sapir conducted a similar analysis of insurance-claims data and found that between 2017 and 2023, 5,288 to 6,294 minor natal girls underwent double mastectomies for gender dysphoria.
[ Sapir added these caveats: “2023 data are incomplete, making it premature to conclude that a dip occurred that year, relative to previous years. Second, even the liberal estimates are an undercount, as the data are limited by two constraints: the procedures had to be covered by insurance, and patients had to have a preexisting diagnosis of gender dysphoria.” ]
In an email to me regarding the Do Not Harm analysis, Dr. Sapir said: “The data on surgery align with our findings, though we looked at a broader range of years (2017-2023) and exclusively at mastectomy. In both cases, the analyses were deliberately based on conservative assumptions; with a field as contentious as this, it’s better to underestimate than to overestimate.”
“The practice of sex ‘change’ surgery in minors is not nearly as rare as its advocates have said,” Dr. Sapir told me. Indeed, the Do No Harm analysis re-affirms my previous reporting about how Harvard recently falsely claimed that gender-transition surgeries are rare among minors.
Dr. Sapir argued that at least for surgeries, the Do No Harm analysis has superseded an analysis conducted by the data analytics firm Komodo Health Inc. on behalf of Reuters, which was published in Oct. 2022. Komodo’s data for medication-based transition treatment was in the general ballpark of Do Not Harm’s. They found that between 2017 and 2021, 4,780 minors with gender dysphoria received puberty blockers and 14,726 received cross-sex hormones. But that analysis identified only 776 gender-transition surgeries.
[ Komodo Health Inc.'s findings for Reuters in 2022 ]
Also, a study published in Sept. 2023 in the journal Cureus analyzed data from the American College of Surgeons National Surgical Quality Improvement Program Pediatric database. From 2018 to 2021, it identified just 108 minors who received such surgeries. But it did identify a swift increase in the number of surgeries with each passing year, similar to the growth in all types of gender-transition interventions identified by Komodo.
Top 12 Children’s Hospitals Providing Gender-Transition Treatment and Surgeries to Minors
Do No Harm assembled a list it derisively referred to as the “dirty dozen” of the “worst-offending children’s hospitals promoting sex change treatments for minors.”
Their criteria included:
The number of gender-transition patients under age 18
Whether the institution had a dedicated pediatric gender clinic that advertised gender-transition treatment
Which treatments and procedures were offered (surgeries put a clinic higher on the list)
The number of gender-transition treatment prescriptions written
The dollar amount of related medical claims
The promotion of gender-transition treatment within the community
Activism and public support by an institution and its leaders of what Do No Harm referred to as “gender ideology”
The top dozen hospitals includes:
The Children’s Hospital of Philadelphia, with 122 minor patients receiving gender-transition treatment, 5 of whom received surgery. They submitted $230,784 in bills over the five-year period.
Connecticut Children’s Medical Center in Hartford
Children’s Minnesota in Minneapolis
Seattle Children’s
Children’s Hospital Los Angeles
Boston Children’s Hospital (which in 2007 set up the nation’s first pediatric gender clinic, importing a treatment model pioneered by Dutch researchers)
Rady Children’s Hospital in San Diego
Children’s National Medical Center in Washington, DC
UCSF Benoff Children’s Hospital Oakland
Children’s Hospital Colorado in Aurora
UPMC Children’s Hospital of Pittsburgh
Cincinnati Children’s Hospital Medical Center
For a rather famous—or, according to gender-medicine skeptics, infamous—example of how Boston Children’s has advertised gender-transition surgeries for minors, check out the video below. It was first published in Aug. 2022, but was later taken down amid a firestorm of criticism over the OB/GYN, Dr. Frances Grimstad, effervescently describing what she calls “gender-affirming hysterectomies” for minors with gender dysphoria. But the video is still available via the internet archive.
Many of the doctors at these top children’s hospitals, such as UCSF’s Dr. Jack Turban, may have established themselves as the face of the pediatric gender medicine field. But only about 10 percent of claims for pediatric gender-transition treatment and surgeries are coming from children’s hospitals, Do Not Harm found. The vast majority of care is provided by non-pediatric clinics or hospitals.
Data Broken Down By State
“There are lots of ideas that this is a rare event, lots of ideas that this is localized to just a few places,” Dr. Goldfarb said of pediatric gender-transition treatment at the Monday press briefing. “We thought it was really crucial that we develop an approach that allows you all, as representatives of the people, to be able to inform people in their local hospitals and locales exactly what’s happening.”
Accordingly, users of the Do Not Harm website can zoom in to individual states to analyze data on local health care practices and billing histories. For example, over the five-year period of the analysis, California health care providers treated at least 2024 minors with gender-transition treatments, billing nearly $29 million for 1359 surgeries and prescribing puberty blockers and cross-sex hormones to 725 children.
Zooming in a little closer, here is a segment of the roster of California care providers and their respective shares of the tally:
Here is share of those cases from Children’s Hospital Los Angeles:
The Top Doctors and Medical Institutions By Billing
Gender-transition treatment is a substantial source of revenue for a number of large hospitals. Keep in mind, however, that even if Mount Sinai brought in all $8.2 million they billed for such medial care over five years, this would only have amounted to 0.05 percent of the hospital system’s total revenues during that period, of about $17 billion.
The following figures suggest that there is a small club of individual doctors who billed in excess of $2 million over a five-year period for gender-transition treatment for minors. A single doctor at Boston Children’s billed in excess of $5 million.
Overall trends
Interestingly, even in states where gender-transition treatment and surgeries for minors has remained legal, there was a sharp downturn in prescriptions and operations in 2023 in some but not all states—including California, Colorado, Illinois, New York, Pennsylvania and Washington. Do No Harm told me this was not because the data from 2023 is incomplete.
My recent reporting suggests that it is possible that in the face of backlash against pediatric gender medicine and waves of bad publicity—including the publication of Britain’s Cass Review, the release of the WPATH Files and the unsealing of damaging documents about WPATH in the federal lawsuit in Alabama—physicians in this field have started to become more conservative in their prescribing practices. Also, it is possible that parents have become more reticent about consenting to such treatment in the face of waves of news that might lead them to question the related evidence base.
Also, in the wake of gender-affirming surgeon Dr. Blair Peters’ recent conversation on Instagram Live with the American Society of Plastic Surgeon’s president, many wondered how many minors Dr. Peters has operated on. Dr. Peters works at Oregon Health and Science University. OHSU Portland had at least 19 minor patients who received gender-transition surgeries over the past five years.
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About the Author
Benjamin Ryan is an independent journalist, specializing in science and health care coverage. He has contributed to The New York Times, The Guardian, NBC News and The New York Sun. Ryan has also written for the Washington Post, The Atlantic, The Nation, Thomson Reuters Foundation, New York, The Marshall Project, PBS, The Village Voice, The New York Observer, the New York Post, Money, Men’s Journal, City & State, Quartz, Out and The Advocate.
Learn more about Ryan’s work on his website, follow him on X @benryanwriter, and subscribe to his Substack.
