On January 20, 2025, the Trump administration issued an executive order titled Protecting Children from Chemical and Surgical Mutilation. This order required the United States Secretary of Health and Human Services (HHS) to “publish a review of the existing literature on best practices for promoting the health of children who assert gender dysphoria, rapid-onset gender dysphoria, or other identity-based confusion” within 90 days.
That review has now been published. Although compiled much more quickly and with less emphasis on systematic reviews of the academic studies on the topic, this HHS Review is the United States’ version of the Cass Review. It reaffirms the Cass Review’s central findings that medical transitioning for minors is not supported by evidence. Instead, psychotherapy (or talk therapy) is a superior approach to treating gender dysphoria.
Much of what is reported in this HHS report has already been presented elsewhere, but there are a few new matters we haven’t considered yet. Two overarching themes of the report are the need for evidence and the need for ethics in this field.
The Need for Evidence
HHS stresses the need to rely on evidence-based medicine rather than intuition, personal experience, or hoped-for results in “pediatric gender medicine” (the report’s preferred term for medical transitioning for minors). Evidence-based medicine makes use of systematic reviews – academic exercises that analyze all the studies available on a certain topic. Ordinary academic studies have differing methodologies, settings, researchers, and findings, but systematic reviews analyze the evidence of many studies.
The HHS report analyzed 17 systematic reviews on the effects of social transition, puberty blockers, cross-sex hormones, surgery, and psychotherapy for minors. While there are many individual studies on these interventions, and many suggest that medical transitioning can have benefits, the systematic reviews expose major flaws in methodology. The review found a distinct lack of randomized controlled trials, small sample sizes, small effects, inconsistent study findings, and publication bias.
HHS concluded that, in all these areas, the quality of evidence surrounding the benefits of these interventions is very low.
HHS concluded that, in all these areas, the quality of evidence surrounding the benefits of these interventions is very low. (The assessment tool they used grades the certainty of evidence as high, moderate, low, or very low certainty. Very low certainty means that we have no idea what the true effects of medical transitioning are.)
There is very low certainty that puberty blockers lessen gender dysphoria or improve mental health. There is also very low certainty that cross-sex hormones reduce gender dysphoria or improve mental health. Likewise, there is very low certainty that surgeries (predominantly mastectomies among minors) ease gender dysphoria or enhance mental health, particularly when it comes to suicidality and depression. Little quality research has been done on the effects of psychotherapy either, leading to little certainty about whether talk therapy will achieve desired results either.
The same is generally true of the harms of all these interventions. Because of the bias in the medical community and academia in favour of medical transitioning, researchers have tended not to evaluate various harms associated with pediatric gender medicine. While all sorts of harms – from lower bone density to reduced IQ to cardiovascular disease – have been documented, there is low certainty that medical transitioning causes these outcomes.
Psychotherapy (talk therapy), however, has virtually no known risks or harms. And so, while there are both uncertain harms and benefits of medical transitioning, there are only uncertain benefits for talk therapy. The lack of the risk of harm in psychotherapy is one of the reasons why the review recommends this treatment for gender dysphoria.
Another point in favour of psychotherapy is that the highest quality clinical practice guidelines – what health care professionals depend upon in their day-to-day care of patients – recommend this over medical transition. The guidelines issued by Sweden and Finland are ranked the highest quality standards of over a dozen standards around the world. Both recommend psychotherapy over medical transitioning for minors.
Many of the guidelines that recommend medical transitioning are deeply flawed. For example, the HHS report devotes a whole chapter to critiquing the World Professional Association on Transgender Health (WPATH) and their Standards of Care 8. These standards carry great weight in the United States, Canada, and many other countries. However, in developing the latest standards, WPATH suppressed systematic reviews of the evidence because they didn’t yield the desired results.
Every member of the guideline development group arguably had a conflict of interest, making them biased in favour of medical transitioning. In order to participate in the guideline drafting process, researchers were required to submit their “planned results and conclusions” to WPATH before even beginning to write their manuscript. The group replaced mentions of patients’ “wishes” with “needs” to frame them as “medically necessary” solely to qualify for insurance funding. And the group removed minimum age recommendations not because of evidence, but because of a stakeholder’s ultimatum that their support for the standards was conditional on leaving age restrictions out.
In developing the latest standards, WPATH suppressed systematic reviews of the evidence because they didn’t yield the desired results.
The Need for Ethics
As focused as the report is on ensuring that treatment for gender dysphoria is based on evidence, the report also stresses the need for ethical judgement in this area.
Advocates for “gender-affirming care” seem to apply few ethical considerations to their work. Does a minor want to medically transition? If yes, according to the model of gender-affirming care, then they are morally entitled to puberty blockers, cross-sex hormones, or surgery.
But there are many more ethical considerations that the HHS report touches upon:
- Can minors give fully informed consent to medical transitioning?
- Should doctors simply follow the wishes of their patient over their own professional judgement?
- Do the possible benefits of medical transitioning outweigh the possible harms?
- Is it just to provide a medical transition when psychotherapy (or simply doing nothing) may lead to a better outcome?
- Should a medical transition (with its irreversible consequences) be offered before investigating any mental health conditions?
- Should a medical intervention like a medical transition be provided without a medical diagnosis of gender dysphoria?
- Is a patient likely going to regret undergoing a medical transition?
An ethical practitioner of medicine must consider all of these questions before even considering recommending a medical transition. If even one of these ethical tests is failed, a medical transition is ethically wrong.
If even one of these ethical tests is failed, a medical transition is ethically wrong.
Additional Points
It has been well documented for decades that over 80% of cases of pre-pubescent gender dysphoria resolve naturally after puberty. These studies were based on cases of gender dysphoria (largely in pre-pubescent boys) before transgenderism became mainstream and before rapid-onset gender dysphoria was a recognized phenomenon. Because of the novelty of this new presentation of gender dysphoria in a new group (largely in mid- or post-pubescent girls), there was little data on whether this new form of gender dysphoria would persist or also go away naturally. The HHS report cites a German study of insurance claims and found that “over 70% of adolescent females aged 15-19 no longer had the diagnosis five years later” (70).
So, not only does gender dysphoria in young children tend to go away naturally, so too does gender dysphoria in adolescents. This is another blow to the claim that medical transitioning is an appropriate response to gender dysphoria.
Another important point made in the report is that, “because contemporary gender medicine countenances a multiplicity of ‘genders,’ [there is a] newer emphasis on embodiment goals [that] moves beyond the ‘sex change’ framework of previous decades” (231). In other words, clinicians aren’t always trying to turn a “full female” into a “full male” by giving her give puberty blockers, cross-sex hormones, and every possible surgery. Many people who identity as non-binary or queer or agender might want various combinations of these interventions to achieve their desired appearance. The greater the variation in the treatments and surgeries demanded, the harder it will be to collect and evaluate high quality evidence on the outcomes of various interventions.
Conclusion
This HHS report supports the growing consensus around the world that medical transitioning for minors needs to stop. Canada’s two largest English-speaking peers – the United Kingdom and the United States – have come out against the practice. And two countries that routinely rank as the happiest, most developed, and most progressive countries in the world – Sweden and Finland – have also curtailed the practice. It is time for all of Canada to follow suit.