Is Britain tiptoeing away from a medical scandal? Until recently, many gender specialists in the National Health Service (NHS) treated trans-identifying children by broadly following an “affirmative” approach which accepts patients’ self-diagnosis as the starting-point for treatment. That can mean the prescription of puberty blockers from early adolescence, followed by cross-sex hormones. But Britain now appears to be changing tack. Next spring the NHS will close its specialist youth gender-identity clinic in England, the Gender and Identity Development Service (GIDS) at the Tavistock foundation trust in London. It will be replaced by eight regional centres in which gender services will be integrated with other mental-health services. That is partly because GIDS had long waiting lists. But it also reflects concerns that in the hurry to affirm gender identity, other conditions were ignored. Children with gender dysphoria often experience comorbidities, including autism, depression and eating disorders.

Following extensive stakeholder engagement and a systematic review of evidence, England’s National Health Service (NHS) has issued new draft guidance for the treatment of gender dysphoria in minors, which sharply deviates from the “gender-affirming” approach. The previous presumption that gender dysphoric youth under 18 need specialty “transgender healthcare” has been supplanted by the developmentally-informed position that most need psychoeducation and psychotherapy. Eligibility determination for medical interventions will be made by a centralized Service and puberty blockers will be delivered only in research protocol settings. With the new NHS guidance, England joins Finland and Sweden as the three European countries who have explicitly deviated from WPATH protocols and devised treatment approaches that sharply curb gender transition of minors. Psychotherapy will be provided as the first and usually only line of treatment for gender dysphoric youth.

When Jane Clark’s 15-year-old daughter told her that she thought she might be gay, Dr Clark, a paediatrician who calls herself a “typical west-coast liberal”, said, “ok, great.” When the child a few months later said she thought she was non-binary, “I was, like, I don’t know what that means, but ok.” She found a gender therapist for her child, expecting a period of therapy.

The damage done is immeasurable. No one knows how years of ideological dogma, inappropriate treatment and a culpable failure to consider the overall mental welfare of the children treated by the Tavistock Clinic will affect the thousands referred to its Gender Identity Development Service. Yesterday the government thankfully brought the scandal to a swift halt. In the wake of a devastating report in March on the clinic’s reckless prescription of puberty blockers, ministers have shut it down altogether. Treatment of children questioning their gender identity will now be handled instead by established and respected regional children’s hospitals. Disbanding the Tavistock is not before time.

The UK’s National Health Service will close the world’s largest pediatric gender clinic, the Gender Identity Development Service in London (GIDS) often known as the Tavistock, after the NHS Trust which houses it.  An independent review condemned the clinic as “not a safe or viable long-term option” because its interventions are based on poor evidence and its model of care leaves young people “at considerable risk” of poor mental health. The clinic must close by spring 2023

Since 2010, the number of teenage girls referred to the Tavistock Gender Identity Development Service has increased by 5,000 per cent. Now former patients and staff members are speaking out. For me it began with a graph. In 2017, I was shown a chart of children referred to GIDS, the Tavistock and Portman Trust’s Gender Identity Development Service clinic in northwest London. Overall case numbers had risen – from just 72 in 2009-10 to 1,807 in 2016-17 – but there was something more puzzling. Female referrals, once a fraction of males, now made up 70 per cent: from 32 to 1,265. The number of teenage girls with gender dysphoria (ie profound discomfort with their biological sex) had risen by 5,000 per cent in 7 years. My journalistic curiosity was sparked, more so when I could find no mention of this in the mainstream press. The only people collecting data and testimony were online parents’ groups in Britain and the US. Moreover, their stories revealed a distinct pattern, repeated worldwide from Australia to Sweden.

A recent study published in Pediatrics examined the 5-year gender identity development trajectory of transgender-identified children who underwent early social gender transition (SGT). The children were, on average, 6-7 years old at the time of SGT. Five years later, at the average age of 11-12, almost all—97.5%—continued to identify as transgender, including a small subset (3.5%) developing a non-binary identification. Only 2.5% of the children desisted from transgender identification by the end of the study period, and re-identified with their sex. Some of the recent news coverage of this study incorrectly stated that the study confirmed that children who claim a transgender identity rarely change their minds. This statement is only partially accurate. A more accurate statement is that the study suggests that children who claim a transgender identity and undergo early social transition rarely change their minds, at least into their early teen years.

Last week, the U.S. Department of Health and Human Services (HHS) issued an official document entitled "Gender-Affirming Care and Young People". The document purported that the use of “gender-affirming” hormonal and surgical interventions for youth struggling with gender dysphoria is “crucial to overall health.” In light of the proposed rule announced by the HHS earlier this year mandating the provision of hormonal and surgical interventions, the debut of this official document carrying the official HHS seal is noteworthy. Below, we fact-check the accuracy of the claims made in the newly-released HHS document. We also reflect on the process used by HHS to arrive at the conclusion that the “gender-affirming” care pathway must be scaled widely—at precisely the same time that a growing number of public health authorities (Sweden, UK, Finland) have come to the opposite conclusion and intend to tightly regulate the access of such interventions for youth.

Trans-identified youth present to clinicians as strongly desiring hormones and surgery. However, this conviction should not be confused with the capacity to carefully consider the consequences of gender transition, argues a recent article about informed consent in gender medicine, published in the peer-reviewed Journal of Sex & Marital Therapy. The authors observe that in recent years, a growing number of adolescents and young adults have declared a transgender identity and sought “gender-affirmative” interventions. The medical and surgical interventions that comprise the “gender-affirmative” care pathway aim to change the body so that it matches the young person’s “gender identity”: a subjectively experienced inner sense of self as a male or female, or increasingly commonly, somewhere in-between.

The National Academy of Medicine in France has issued a press release in which it cautions medical practitioners that the growing cases of transgender identity in young people are often socially-mediated and that great caution in treatment is needed. The Academy draws attention to the fact that hormonal and surgical treatments carry health risks and have permanent effects, and that it is not possible to distinguish a durable trans identity from a passing phase of an adolescent's development. SEGM has translated the press release, which is provided in full below. Both the original press release in French, and its unofficial SEGM translation are appended.

In February 2022, the Swedish National Board of Health and Welfare (NBHW) issued an update to its health care service guidelines for children and youth <18 with gender dysphoria / gender incongruence. This update contains 14 distinct “recommendations,” with justification for each, referencing a recently completed systematic review of evidence. Three of the recommendations provide guidance for social support for gender dysphoric youth and their families; nine focus on the assessment of gender dysphoria/gender incongruence; and two target hormonal interventions: puberty blockers and cross-sex hormones. Additional updates are anticipated later in 2022.

Studies in the field of gender medicine are notoriously unreliable, plagued by small samples, lack of controls, confounding, and bias. This is true for even the “best” studies in the field,  such as the “Dutch study”— the foundation of treating gender dysphoric youth with hormones and surgery.

Adolescents who identify as transgender are vulnerable to suicidal thoughts and self-harming behaviors. This fact, frequently reported by the news media, is often used as the justification for the rapid provision of "gender-affirming" hormonal and surgical interventions to gender-dysphoric adolescents: “Fifty percent of transgender youth attempt suicide before they are at age 21,” declared the mother of Jazz Jennings, the most famous transgender youth in the English-speaking world. Although the elevated rate of suicidality in trans-identified youth is well-documented, a closer examination of the risk of suicide among trans-identified youth reveals a more complex picture.

The Society for Evidence-Based Gender Medicine (SEGM) welcomes WPATH SOC8’s acknowledgement of the profound shift in the incidence of gender dysphoria/gender incongruence and its presentation among youth, and the acknowledgement of the risk of inappropriate medical transition of youth. We also commend the increased focus on psychotherapy assessments, since gender incongruence in youth can arise from multiple causes and may have multiple paths to resolution.  At the same time, we are disappointed by the significant methodological limitations in the draft SOC8 guideline.

What happens when a young person's intensely experienced desire to undergo medical transition is granted, with minimal attention paid to the factors contributing to the development of gender dysphoria, and with no attempts to ameliorate the distress non-invasively first? A new publication, Gender Detransition, a Case Study by Lisa Marchiano, presents a case study of a young natal female detransitioner. This case study is an effort to elucidate the complex characteristics and issues involved in the desire for transition and detransition in the novel population of adolescents with post-puberty onset of gender dysphoria. Marciano observes the limitations of the "gender-affirmative" care model and calls for further research better understand this population.

Consistent with the principle, “First, do no harm,” in Clinical and Ethical Considerations in the Treatment of Gender Dysphoric Children and Adolescents: When Doing Less Is Helping More, psychologist David Schwartz, Ph.D. exhorts clinicians to treat children and adolescents with gender dysphoria (GD) using psychotherapy rather than pharmacological and surgical interventions. He asserts, “in the treatment of children and adolescents, no matter what the diagnosis, encouraging mastectomy, ovariectomy, uterine extirpation, penile disablement, tracheal shave, the prescription of hormones which are out of line with the genetic make-up of the child, or puberty blockers, are all clinical practices which run an unacceptably high risk of doing harm.”

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) released its first position statement addressing the mental health needs of people with Gender Dysphoria/Gender Incongruence in August 2021, which was followed by an update in September 2021. Prior to this, the college’s position in relation to Gender Dysphoria was contained within the position statement on LGBTQ mental health. This new statement is the first position statement released by a professional body, as far as we are aware, which does not specifically endorse a gender-affirming approach.

Recently, The Lancet published an editorial defending broad availability of medicalization of gender-dysphoric youth. The editorial was written in response to several US bills that aim to limit the use of hormones and surgery in minors. It asserted that hormonal and surgical interventions for gender dysphoric youth are proven treatments and that regret for gender transition is below 1%. A vigorous scientific debate ensued, revealing the deficiencies in these claims, and highlighting the importance of platforming debate in this contested area of medicine.

A new study of individuals who medically or surgically transitioned and subsequently detransitioned, suggests that the rate of detransition may be significantly underestimated. According to the study, which examined the survey responses of 100 detransitioners, fewer than 1 in 4 notified their treating providers of the decision to stop or reverse their transition.

According to a recently published medical news article in Sweden, representatives of all of Sweden's six university clinics that treat children and young people with gender dysphoria participated in a meeting called by Sweden's National Board of Health and Welfare to discuss the approach to hormonal interventions for gender-dysphoric youth.

Last week, the American Academy of Pediatrics (AAP) rejected SEGM’s application to share the latest evidence regarding the practice of pediatric gender transition at AAP's upcoming annual conference in Philadelphia in October 2021. This rejection sends a strong signal that the AAP does not want to see any debate on what constitutes evidence-based care for gender-diverse youth.

The Society for Evidence-Based Gender Medicine (SEGM) has filed an Amicus Brief with the 9th Circuit Court of Appeals, challenging the position held by WPATH and set forth in WPATH’s and the Pediatric Endocrine Society’s Amicus Brief that mastectomies for gender-dysphoric adolescents are evidence-based. 

A year ago, the Finnish Health Authority (PALKO/COHERE) deviated from WPATH's "Standards of Care 7," by issuing new guidelines that state that psychotherapy, rather than puberty blockers and cross-sex hormones, should be the first-line treatment for gender-dysphoric youth. This change occurred following a systematic evidence review, which found the body of evidence for pediatric transition inconclusive. 

In December of 2020, the Endocrine Society, in partnership with the Pediatric Endocrine Society, released a Position Statement regarding transgender health. That position statement asserts that there is a biological underpinning to transgender identification and that hormonal and surgical interventions for those suffering from gender dysphoria are safe and effective. The statement additionally claims that such interventions are "standard of care." A recently published peer-reviewed letter to the editor of the Journal of Clinical Endocrinology and Metabolism (JCEM), an official journal of the Endocrine Society, argues that these positions are unsupported by current medical evidence.

Over the last few years, a growing community of detransitioners has formed online. Despite the visibility recently given to the topic in mainstream media, including a recent 60 Minutes episode featuring detransitioners and their stories, detransition is still a poorly understood phenomenon. A recent exploratory cross-sectional study aims to serve as a springboard for further academic research on the subject. It focuses particularly on uncovering the specific needs that detransitioners experience and the support - or lack thereof - that they receive. The study also provides information about the average age of transition, detransition, and the duration of transition among study participants.

Following the 60 Minutes episode earlier this week, which highlighted the controversies surrounding medical interventions for gender dysphoric youth, SEGM has been receiving an increasing number of inquiries about the state of gender care for youth in the United States. One question in particular has been asked most frequently: how difficult or easy is it to obtain hormones and surgeries in the US? There are over 60 pediatric “gender clinics” in the US, according to the Human Rights Commission’s interactive map. However, the total number of clinics and medical offices that provide hormonal interventions to minors is likely much higher, and is currently estimated at over 300. We cannot speak for all the clinics and their practices. However, we can provide some general observations and insights about the state of pediatric gender care in the US.

Update May 08, 2021. The Karolinska Hospital in Sweden recently issued a new policy statement regarding treatment of gender-dysphoric minors. This policy, affecting Karolinska's pediatric gender services at Astrid Lindgren Children's Hospital (ALB), has ended the practice of prescribing puberty blockers and cross-sex hormones to gender-dysphoric patients under the age of 18.

Suppressing puberty in children suffering from gender dysphoria — by administering Gonadotropin-Releasing Hormone agonist (GnRHa) — entails several known risks. One is that patients could “end with a decreased bone density, which is associated with a high risk of osteoporosis” (Delemarre-van de Waal & Cohen-Kettenis 2006). Bone density was one of the outcomes tracked by the English experiment with GnRHa on children between the ages of 12 and 15, launched by the Tavistock clinic in 2011. As the endocrinologists Dr William J. Malone (an adviser to SEGM) and Dr Michael Laidlaw have pointed out, the published results (Joseph, Ting, & Butler 2019) showed that children experienced a significant decline in bone density relative to the norm for their sex and age—as measured by Z-scores. The study tabulated only the mean and the standard deviation of the Z-scores, and so the proportion of children with Z-scores in the abnormal range was unknown.

In 2020, the UK National Institute for Health and Care Excellence (NICE) undertook two systematic evidence reviews of the use of GnRH agonists (also known as "puberty blockers") and cross-sex hormones as treatments for gender dysphoric patients <18 years old. These reviews were commissioned by NHS England, as part of a review of gender dysphoria healthcare led by Dr Hilary Cass OBE. These reviews, which were published earlier this week, make for sober reading. The reviews' major finding is that GnRH agonists lead to little or no change in gender dysphoria, mental health, body image and psychosocial functioning. All the studies evaluated had results of “very low” certainty, and were subject to bias and confounding.

It is a well-established observation that individuals suffering from gender dysphoria (GD) demonstrate an increased prevalence of mental health issues when compared to the general population. One theory that explains the link between GD and mental illness is the minority stress model. Gender-non-conforming and GD youth experience elevated rates of victimization, discrimination, and prejudice. According to the minority stress theory, these adverse experiences are the primary cause of the poorer mental health status of GD individuals. There are two issues which contradict the minority stress theory. First, evidence shows that mental health issues often precede the onset of gender identity concerns. Second, long-term studies have not been able to demonstrate lasting mental health benefits of “gender-affirmative” (hormonal and surgical) interventions. These findings do not support the argument that minority stress is the primary reason for the high co-occurrence of GD and other psychiatric disorders. An alternative explanatory model for the co-occurrence of GD and other forms of distress and mental illness is that both arise as a result of a complex interplay of biological, relational, and cultural factors.

Gender detransition, broadly defined as the interruption or reversal of a gender transition process, has acquired noticeable visibility in recent years. Those who detransition, commonly referred to as "detransitioners," have started to share their experiences on social media and other online platforms, raising substantial questions for clinicians working in the field of gender dysphoria.

The year 2020 has been pivotal in the field of gender medicine. Earlier this month, in a landmark decision, the UK High Court ruled that children under 16 are unlikely to be able to consent to the use of puberty blockers, which the Court deemed to be an experimental treatment. Rather than a “pause button,” the court recognized puberty blockers as the first step in a largely irreversible pathway of medical transition.

In 2018 Andrea Davidson’s 12-year-old daughter, Meghan, announced she was “definitely a boy”. Ms Davidson says her child was never a tomboy but the family doctor congratulated her and asked what pronouns she had chosen, before writing a referral to the British Columbia Children’s Hospital (BCCH). “We thought we were going to see a psychologist, but it was a nurse and a social worker,” says Ms Davidson (both her and her daughter’s names have been changed).

The Society for Evidence-Based Gender Medicine (SEGM) maintains that treatments for gender-dysphoric people should be supported by high quality evidence. We commend the thorough process undertaken by the UK High Court to assess the ability of young people to consent to treatment that has serious side effects and lacks adequate supporting evidence.

In September 2019, JAMA Psychiatry published an article, Association Between Recalled Exposure to Gender Identity Conversion Efforts and Psychological Distress and Suicide Attempts Among Transgender Adults. The article concluded that therapies that did not "affirm" an individual's transgender identity (which the article refers to as "gender-identity conversion efforts / "GICE") lead to severe distress and even suicide attempts. These findings have been used to promote legislative bans on non-affirmative therapies worldwide.

In October 2019, the American Journal of Psychiatry (AJP) published a study from the Karolinska Institute in Sweden, and the Yale School of Public Health which reported that “gender-affirming" surgeries for gender dysphoric patients are associated with improved mental health outcomes (1). Looking at mental health utilization in the year 2015, a retrospective analysis showed that the more time passed since surgery, the fewer mental services were utilized by patients, with an average 8% reduction in mental health ut