Notable Publications in Gender Medicine, September–October 2025

SEGM Digest, Issue 4 (September–October)
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December 1, 2025

This fourth installment of the SEGM Digest continues our work tracking the rapidly expanding literature in pediatric gender medicine. This issue brings together five papers that illuminate the core challenges now facing the field: insufficient methodological rigor, a lack of openness to debate, and policies not grounded in transparent evidence appraisal.

As in previous issues, we offer concise reviews to help busy professionals keep abreast of developments. Readers who wish to engage more deeply with the material will find links to the original publications alongside our analyses.

We welcome comments and suggestions as we continue to refine the Digest, and encourage those who have not yet read Issues 1, 2 and 3 to do so.

SEGM Digest: Issue 4

1. Changes in Suicidality Among Transgender Adolescents Following Hormone Therapy: An Extended Study (Allen, L. R., Dodd, C. G., Moser, C. N., & Knoll, M. M., 2025). A recent study of youth treated with cross-sex hormones at Children Mercy’s gender clinic claimed reduced suicidality after youth began hormone therapy, but potentially serious methodological flaws in data collection and analysis cast doubt on the reliability of this conclusion.

 SEGM reviewFull text (external link)

2. Obstacles to Progress in Paediatric Gender Medicine (Kozlowska, K., Hunter, P., Clayton, A., Kaliebe, K., & Scher, S., 2025). This discussion paper identifies notable differences between pediatric gender medicine and other medical fields, arguing that a return to standard medical practices is necessary for progress.

 SEGM reviewFull text (external link)

3. Censorship of Essential Debate in Gender Medicine Research (Cohn, J., 2025). Research in gender medicine is being undermined by publication bias—the systematic skewing of the literature caused when studies with less favorable or non-significant results are not brought to print. This paper describes how medical journals often evaluate publications critical or supportive of medical gender transition with a double standard, leading editors to delay, downplay, or decline papers that present inconvenient results or challenge the “gender-affirming” treatment pathway.

 SEGM reviewFull text (external link)

4. Challenges of Sexual Life After Detransition: Trauma, Disenfranchized Grief, and Unmet Needs (Anllo, L., 2025). This paper analyzes detransition testimonies to explore the impact of medical gender transition on sexual function, drawing a parallel with the loss of sexual function in cancer treatment.

 SEGM reviewFull text (external link)

5. The Cass Review and Gender-Related Care for Young People in Canada: A Commentary on the Canadian Paediatric Society Position Statement on Transgender and Gender-Diverse Youth (Kulatunga Moruzi, C., Sim, P., Mitchell, I., Palmer, D., & Joffe, A. R., 2025). Canadian researchers critique the Canadian Paediatric Society’s gender affirming position statement, highlighting key shortcomings concerning recent developments in the field.

 SEGM reviewFull text (external link)

1. Changes in Suicidality Among Transgender Adolescents Following Hormone Therapy: An Extended Study. (Allen et al., 2025).

  • Allen, L. R., Dodd, C. G., Moser, C. N., & Knoll, M. M. (2025). Changes in Suicidality among Transgender Adolescents Following Hormone Therapy: An Extended Study. The Journal of Pediatrics, 289, 114883. https://doi.org/10.1016/j.jpeds.2025.114883

A recent retrospective, uncontrolled chart-review based study of 432 gender-dysphoric youth (ages 12–20), treated at Children’s Mercy gender clinic in Kansas City, compared Ask Suicide-Screening Questions (ASQ) scores before and after the initiation of cross-sex hormones (CSH). The mean follow-up was 1.9 years (range 3 months to 5 years). Before hormone initiation (i.e., at baseline), 80% of participants screened negative for suicidal ideation on the ASQ, compared with 93% after hormone initiation (i.e., follow-up). For recent suicide attempts, 97% screened negative at baseline and 99.5% at follow-up. The researchers identified three outcomes in suicidality before and after CSH initiation: unchanged for 77%, increased for 4.6%, and decreased for 18.5%.

The authors subjected the results to a statistical analysis (a repeated-measures ANCOVA), adjusting for age at CSH initiation, time on treatment, and sex. The analysis yielded a statistically significant, “moderate” pre-to-post reduction in suicidality scores. Age, sex, and treatment duration each had no measurable effect. The authors interpreted their results as supporting the claim that CSH reduces suicidality.

However, serious concerns about the study’s data collection and analytic approach undermine this interpretation.

  • Potential undercounting of “after”/follow-up suicidality. The study’s baseline ASQ score was taken from the clinic visit at which CSH were first prescribed, whereas the follow-up ASQ score came from the patient’s most recent visit to any Children’s Mercy clinic, not necessarily the gender clinic. The study’s before–after suicidality comparison was enabled by the hospital’s universal ASQ-based suicide risk screening program, fully implemented by January 2019. However, mental health clinics were exempted from this requirement, as they already used the more comprehensive Columbia Suicide Severity Rating Scale (C-SSRS). Because the study design relied on Mercy’s system-wide ASQ responses, it is likely that post-transition suicidality managed within the mental health clinic setting would have been missed at “follow-up,” as suicidality recorded during these encounters would have been captured using C-SSRS rather than ASQ. This means the study could have potentially substantially underestimated “follow-up” suicidality.
  • Unvalidated use/misuse of ASQ scores.  As has already been noted in a published critique, the study used an unvalidated ASQ scoring method to quantify suicidality. The 4-item ASQ was designed to be scored in a binary way, with 0 indicating that none of the scores were endorsed and 1 indicating that one or more items were endorsed.  Instead of this validated approach, Allen et al. summed the response to create a 0–4 “score” that they then entered as a continuous variable for their ANCOVA analysis. However, there is no empirical basis for assuming that suicide risk increases linearly with the number of positive ASQ responses. This undermines the validity of the ANCOVA analysis upon which the study’s conclusions rests.
  • Regression to the mean. Youth typically seek a gender-clinic consult at the height of their distress. Because extreme emotional states naturally subside over time, distress often diminishes on its own. This statistical tendency—regression to the mean—means that suicidality scored at peak distress will almost always look better later, even if no treatment produced the change.
  • Inflated baseline reporting. There is a considerable possibility that some high scores at baseline are inflated because youth feel pressure to signal severe distress in order to secure parental or clinical approval for hormones, one of the unfortunate consequences of the “transition or suicide” narrative promoted by some gender clinics. This type of effect may have been further heightened by proposed “gender-affirming” treatment bans for minors that occurred during the study time frame.
  • Confounding from co-occurring mental health treatments. Mercy’s ASQ-based suicide screening protocols indicate that all youth who screened positive on the initial ASQ administered at the time CSH were prescribed would have been automatically referred to a social worker and/or additional mental health support, including safety planning (with means-restriction counselling), and, when indicated, referral to outpatient care or transfer to inpatient care. These interventions are themselves well-established, evidence-based strategies for reducing suicidality, making it impossible to attribute changes in ASQ responses specifically to CSH use.
  • Other uncontrolled confounding. There is a well-documented natural decline in adolescent suicidality after age 16, which could account for some of the observed suicidality reduction over time. Major external events, such as the COVID-19 pandemic—an event that materially affected suicidality trends during the study’s reporting period—may also have influenced outcomes. Other confounders, such as expectation of positive treatment effects (placebo effects) and attention, validation and care of medical professionals can also have positive effects. The study’s methodology did not adequately account for these confounders.
  • Uncertainty about treatment status. The study does not explain how Allen et al. verified patients were still on CSH at follow-up. At a 2-year median follow-up the discontinuation rate was only 1.6% (7/432). This figure is far lower than the 25.6% 4-year discontinuation and the estimated ≈15% discontinuation by 2 years among adolescents who initiated gender-affirming hormones before age 18 in a recent study that assessed discontinuation via prescription refills. If Allen et al. assumed that patients were still taking CSH unless they explicitly informed the gender clinic they had stopped, discontinuation may be considerably underestimated. One study we have reviewed found that over 75% of detransitioners did not notify their treating clinician that they had discontinued treatment. Thus, it is plausible that some “post-treatment” ASQ scores—recorded in other departments but treated as evidence of ongoing CSH—were actually collected from individuals who had already discontinued CSH / detransitioned. The authors’ response to this specific question from journalist Ben Ryan—“Even if patients stopped hormone treatment, they could still provide suicidality data in the larger Mercy system when seen for other reasons”—only heightens concern that treatment continuation was not validated.
  • Lack of transparency in reporting. Allen et al. report a sample of 432 cases with paired before-after ASQ scores but do not disclose the size of the full CSH-treated cohort nor indicate how many patients lacked ASQ data or were otherwise excluded. Standard reporting would include a flow diagram showing these important details. Without this information, readers cannot judge how complete the study sample is, and the potential impact of selection bias and loss to follow-up on the findings.

SEGM comment: There is no reliable evidence that CSH reduce suicidality in youth and adults with gender dysphoria, and Allen et al.’s study does not close this gap. Its limitations significantly undermine their claim to provide clinical evidence that CSH lowers suicide risk. It is unclear whether the reported drop in suicidality is reliable, given that the study likely missed assessments in mental-health settings—the very places where such concerns are most likely to surface and be recorded. Further, even if suicidality was accurately recorded, the observed decline could just as plausibly reflect the support routinely provided to all patients who screen positive on the ASQ, along with other talking therapies and community support, rather than the effect of CSH. 

Of note, Children’s Mercy closed its gender clinic to new patients in August 2023 following passage of Missouri’s Save Adolescents from Experimentation (SAFE) Act.

2. Obstacles to Progress in Paediatric Gender Medicine

  • Kozlowska, K., Hunter, P., Clayton, A., Kaliebe, K., & Scher, S. (2025). Obstacles to progress in paediatric gender medicine. European Journal of Developmental Psychology, 1–31. https://doi.org/10.1080/17405629.2025.2546574

In “Obstacles to Progress in Paediatric Gender Medicine,” Australian Child and Adolescent Psychiatrist, Kasia Kozlowska and colleagues argue that progress hinges on repairing the broken “chain of trust” by reinstating normal scientific scrutiny, transparent guideline development, and developmentally informed clinical reasoning—standards routinely applied in other areas of pediatric care.

Current problems identified in the field include the following:

  • False suicide-risk narrative. A false and potentially dangerous narrative about suicide risk is characterized by exaggerated claims of suicide incidence, non-evidence-based claims that “gender-affirming” treatment decreases this risk, and manipulative statements regarding suicide by clinicians attempting to secure parental consent for GAT. Not only is this narrative untrue, but it likely exacerbates suicidality among vulnerable young people through social contagion and social-script mechanisms.
  • Research and guideline integrity failures. WPATH has engaged in the suppression of evidence, gender pediatricians have delayed publishing research findings perceived to be unfavorable to the gender affirming treatment model, and major guidelines rely on problematic (often circular) referencing. The authors argue that such failures by professional clinical organizations and health authorities have broken the ‘chain of trust’ on which this area of medicine relies.
  • Neglect of developmental complexity. Insufficient consideration is given to the full complexity of child and adolescent development, and there is inadequate research into the full range of biopsychosocial factors that might contribute to the etiology of child and adolescent gender dysphoria.
  • Blind spot about homosexuality. A blind spot exists regarding the possibility that some young people experience gender dysphoria either as a normal developmental phase of homosexuality or as a response to external or internalized homophobia.
  • Terminological confusion. The failure to clearly distinguish between the terms “sex” and “gender” risks undermining patient health and well-being.

In their conclusion, Kozlowska and colleagues emphasize that gender medicine should not be treated differently from other medical fields. To advance the field, gender medicine must ensure adherence to ethical and evidentiary standards seen in evidence-based medicine. Unproven interventions, such as GAT, require a cautious and open-minded approach. Additionally, health authorities must decide whether to make these treatments widely available or classify them as research until more evidence is gathered on their efficacy and potential risks.

SEGM comment: We welcome this concise yet wide-ranging critique of current pediatric gender practices, which underscores that gender medicine, like any other field, must be held to the same methodological and ethical standards as any other medical field. Clinicians, policymakers, and professional bodies must engage seriously with these critiques and align their practice with the standards of evidence-based medicine.

3. Censorship of Essential Debate in Gender Medicine Research

In “Censorship of Essential Debate in Gender Medicine Research,” researcher J Cohn highlights serious publication integrity problems that plague the professional peer-reviewed literature in the field of gender medicine. Cohn argues that some medical journals are failing in their duty to ensure that publications provide accurate information and/or to allow post-publication correction or debate. Cohn provides multiple examples that illustrate incorrect or misleading statements in published articles that support gender affirming treatment. This includes exaggeration of the benefits, under-acknowledgment of the harms, overstatement of the evidence base, and denigration of alternative approaches. Cohn also provides several examples demonstrating that journal editors have rejected Letters to the Editor that offer rigorous critiques of published articles. The serious adverse consequences for patient care arising from this lack of integrity and censorship in the published literature are also discussed.

SEGM comment: By documenting how misleading claims in support of medical transition are shielded from scrutiny while critical publications are suppressed, this article highlights a systemic problem of publication bias that directly endangers the quality and safety of care for gender-dysphoric people.

4. Challenges of Sexual Life After Detransition: Trauma, Disenfranchized Grief, and Unmet Needs

Lisa Anllo, a sex therapist, explores the iatrogenic harm that gender-affirming medical and surgical treatments may cause to sexual function, particularly for those individuals who experience grief and regret after transitioning back to a gender identity aligned with their natal sex. The article sheds light on the unmet care needs of this group, emphasizing the profound grief related to the loss of normal sexual function following gender-affirming interventions, which is often perceived as medical trauma. Drawing upon public accounts of detransitioners, Anllo provides numerous illustrative examples. She highlights that these individuals face stigma and marginalization due to political pressure aimed at silencing their narratives, downplaying their distress, and neutralizing any perceived threats to unrestricted access to gender-affirming care.

Additionally, she argues that this political climate has stifled the dissemination of information about iatrogenic harm to sexual function, leading to a lack of professional continuing education on the topic and creating significant gaps in care. Anllo also draws parallels between unmet needs due to iatrogenic medical harm in gender care and similar issues in cancer care, where sexual wellness concerns for survivors are often overlooked and unrecognized, resulting in disenfranchised grief. Anllo concludes by cautioning that well-intentioned professionals must be culturally informed, so that they can respect and empathize with the complex grief reactions related to medical harm, as well as the anger and distrust directed at therapists and medical providers viewed as contributors to that harm. Addressing these emotions is essential before offering practical support.

SEGM comment: This is a sober examination that includes harrowing narratives from those sexually harmed by medical transition. Health systems must train and resource clinicians who can respond sensitively and skillfully to the complex grief, anger, and distrust that often follow.

5. Review and Gender-Related Care for Young People in Canada: A Commentary on the Canadian Paediatric Society Position Statement on Transgender and Gender-Diverse Youth

  • Kulatunga Moruzi, C., Sim, P., Mitchell, I., Palmer, D., & Joffe, A. R. (2025). The Cass Review and gender-related care for young people in Canada: A commentary on the Canadian Paediatric Society Position Statement on transgender and gender-diverse youth [letter to the editor]. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-025-03335-8

In this peer-reviewed publication Chan Kulatunga Moruzi and colleagues raise substantial concerns about the 2023 Canadian Paediatric Society Position Statement (CPS-PS), “An affirming approach to caring for transgender and gender-diverse youth.” The authors note that the CPS-PS promotes an affirmative approach rooted in a rights-based perspective, as opposed to an evidence-based approach that emphasizes patient safety and long-term health, exemplified by the Cass Review. In methodical detail, the authors outline the CPS–PS’s numerous shortcomings, including the following:

  • Unreliable guidelines. Dependence on unreliable clinical guidelines (WPATH SOC-8, Endocrine Society, AAP), identified by the Cass Review/York systematic reviews as lacking rigor, transparency, evidence-based grounding, and compromised by circular referencing.
  • Gender identity misrepresented. Presents gender identity as stable, ignoring literature on desistance and detransition and overlooking how gender-related distress may reflect underlying mental health or neurodevelopmental conditions. This promotes transition as the natural treatment trajectory, rather than encouraging open-ended exploration.
  • Demographic changes ignored. Does not address the recent dramatic rise in gender-distressed adolescents, especially girls with high rates of mental health and neurodevelopmental comorbidities. This ignores important epidemiologic shifts requiring deeper investigation beyond increased societal acceptance.
  • Neglect of regret and detransition. Fails to properly discuss increasing evidence of regret and detransition, ignoring accounts of inadequate assessment, diagnostic overshadowing (overlooking comorbidities by attributing presenting problems to gender distress), and insufficient follow-up, thus missing key insights for clinical improvement.
  • Misleading risk-benefit analysis.Exaggerates benefits and understates risks of puberty blockers and hormone therapy. Systematic reviews report very low-certainty evidence for psychological benefit and emerging evidence of serious medical harms. By ignoring this evidence, they are distorting the overall picture.
  • Simplistic approach to informed consent. Overlooks complexities in adolescent informed consent for medical transition. These include developmental limitations in appreciating lifelong health impacts and ethical concerns around progression from puberty blockers to hormones amidst significant evidentiary uncertainty.

They conclude that the CPS-PS is out of step with major international developments in the field, wherein there is a move toward an evidence-based approach prioritizing non-maleficence and beneficence. This approach has resulted in a shift in numerous countries away from the affirmative treatment model toward neutral and supportive psychological care.

Five members of the CPS, including the two authors of the CPS-PS, issued a response on behalf of the Adolescent Health Committee. Their brief statement did not engage with the substantive concerns raised by Kulatunga Moruzi and colleagues. Instead, it reiterated their view that the CPS-PS reflects a careful review of a developing evidence base and is not intended to function as a clinical practice guideline.

SEGM comment: By clearly contrasting a rights-based approach that emphasizes autonomy and self-determined goals with an evidence-based framework built on systematic assessment of benefits and harms, this article highlights critical vulnerabilities of the CPS-PS and similar guidelines. Genuine ethical care for gender-distressed youth requires balancing respect for autonomy with rigorous evidence appraisal and caution where certainty is low.