The Medical Association of the German State of Mecklenburg-Vorpommern (Ärztekammer Mecklenburg-Vorpommern) has issued a letter of support for the SEGM Conference which took place in Berlin in early September 2025. The conference had an official endorsement from the International Association for Child and Adolescent Psychiatry and Allied Professions (IACAPAP), had a keynote speaker from the European Society for Child and Adolescent Psychiatry (ESCAP) board member, and the attendees were welcomed by the head of the German Medical Assembly Dr. Klaus Reinhardt. SEGM's president Dr. Roberto D'Angelo's opening remarks set the stage for four days of vital discussions and debates about the best care approaches for gender-dysphoric youth. Despite the strong show of support from the German and international medical establishment, activist groups began to publicly threaten conference speakers and attendees, as has been reported in German media. In response to the attacks, the Medical Association of the German State of Mecklenburg-Vorpommern (Ärztekammer Mecklenburg-Vorpommern) sent a letter addressed to the three Child & Adolescent Psychiatric Societies in Germany, expressing strong support for the discussions and debates hosted by SEGM. The letter was also forwarded to IACAPAP as well as ESCAP.

We continue our series in this month’s SEGM Digest, which highlights a shift in the youth gender transition debate, with growing focus on ethical and regulatory concerns. We review key bioethics publications and court rulings likely to shape future regulation which came out in June 2025. Despite increased awareness of poor study design in gender medicine, clinicians continue to publish papers claiming safety and benefits. We begin by examining two new studies—one from four U.S.

The following publication by Hannah Barnes appeared in the New Statesman online on 27 May 2025. The article has been reproduced below fully, with permission.

Introducing the SEGM Digest

This issue is the first installment of the SEGM Digest, a new series that will highlight recent influential publications in pediatric gender medicine. When we first launched our Spotlight series in 2019 the field was producing relatively few publications. As of 2025, however, the volume of published research and guidance documents has surged, now reaching dozens of publications per week.

The summary cuts to the chase. “The evidence for benefit of paediatric medical transition is very uncertain, while the evidence for harm is less uncertain.” When medical interventions pose unnecessary, disproportionate risks of harm, “healthcare providers should refuse to offer them even when they are preferred, requested, or demanded by patients.” Claims that distressed children who do not transition face greater risk of suicide “are not supported by the evidence”. The report includes a review of 17 previous systematic reviews on the subject, many conducted in Europe, to evaluate the evidence for benefits and harms of PMT. It finds that the overall quality of evidence on the effects of intervention is “very low”. What is more, the report says the risks of PMT include sterility, sexual

The field of youth gender medicine remains in disarray, with increasing recognition of the harms of gender-affirming interventions clashing against continued reliance on unscientific “consensus” guidelines that bypass rigorous evidence-based standards. The German Guidelines acknowledge that most youth with gender-related distress should not undergo medical transition, but they fail to provide a clear method for distinguishing between transient and persistent cases, effectively enabling widespread adolescent transitions.

Sallie Baxendale’s new article "How to be a Better Doctor" in the British Journal of Hospital Medicine shows how personal biases can overshadow objective evidence, highlighting pediatric gender medicine as a key example. She contrasts systematic reviews (like the Cass Review) with expert-consensus documents, urging the use of Graham’s Hierarchy of Disagreement to foster clear, bias-free debate.

What has SEGM been up to this year? As we reach the end of 2024, we wanted to look back at this year's major developments in the field of youth gender medicine and look ahead to the challenges and opportunities 2025 presents.

The following publication appeared in the Economist online on December 2, 2024. The article has been reproduced below fully, with permission.

Italy's National Bioethics Committee (CNB) updated its stance on the use of puberty blockers to treat gender dysphoria. The November 2024 guidance states that puberty blockers should only be provided after mental health interventions failed, and only in the context of proper research trials. The CNB's key recommendations are:

McNamara et al 2024's “An Evidence-Based Critique of the Cass Review” alleges that the Cass Review “repeatedly misuses data and violates its own evidentiary standards,” is “rife with misapplications of the scientific method,” and fails to evaluate the evidence "in a neutral and scientifically valid manner.” A new peer-reviewed analysis concludes that McNamara et al. is not a credible scientific effort, but rather, an attempt to influence U.S. litigation.

Unlike Europe, where national health service (NHS) agencies regulate the practice of medicine, the decentralized nature of the US healthcare system presents a distinct challenge when it comes to healthcare regulation. This is especially evident in the case of youth gender medicine, which relies on "off-label" prescribing.

A new study from Germany indicates that over 60% of young people diagnosed with "Gender Identity Disorder" (F64) no longer have the diagnosis five years later, indicating low diagnostic stability.

The following publication appeared in the Economist online on June 29, 2024. It appeared in the United States section of the print edition under the headline “WPATH/Marking their own homework.” The article has been reproduced below fully, with permission.

The World Health Organization's guideline development group leans heavily on prominent members of WPATH, including WPATH leadership involved in the suppression of unfavorable evidence related to cross-sex hormones.

This Spotlight reviews the German Association of Scientific Medical Societies' 2024 draft guidelines for treating gender dysphoria and gender incongruence in childhood and adolescence and the role of evidence in the process of guideline development.

Earlier this week, the 128th German Medical Assembly, which comprises 250 delegates from 17 German medical associations, passed two important resolutions: to restrict puberty blockers, cross-sex hormones, and surgeries for gender-dysphoric youth under age 18 to controlled clinical trials; and to restrict self-ID laws to those over age 18. 

The European Society of Child and Adolescent Psychiatry (ESCAP) published a policy statement on child and adolescent gender dysphoria. ESCAP is a highly respected umbrella association of 36 Child and Adolescent Psychiatry societies (see Table 1). It enables collaboration among child and adolescent psychiatrists across Europe and holds a widely attended bi-annual professional conference for European child and adolescent psychiatrists.

The Cass Review of England’s gender services for children and young people, initiated four years ago, culminated earlier this week in the publication of the final 388-page report. The report was accompanied by 9 studies (8 of which were systematic reviews of evidence)  supporting the recommendations.

A new peer-reviewed article published in the Archives of Sexual Behavior examines the clinical and ethical implications of puberty blockers for children with gender dysphoria through the lens of “the child’s right to an open future.” As the authors explain, the open future principle refers to “rights that children do not have the capacity to exercise as minors, but that must be protected so they can exercise them in the future as autonomous adults.”

In March 2024, NHS England (NHSE) updated its puberty blockers and cross-sex hormones policies for gender-dysphoric youth. The release of these policies coincides with the launch of the new service model, which will replace the Gender Identity Development Service (GIDS) at Tavistock as of April 1, 2024. The goal of the new service model is to provide holistic care and support for gender-distressed youth, shifting away from the “gender clinic” model of care focused on gender transition of minors.

A new publication* in Sexuologie (the journal of the German Society for Sexual Medicine, Sexual Therapy and Sexual Science/DGSMTW) takes on the issue of the sharp rise in transgender identification in adolescent females, which remains poorly understood.

Summary

A recent study published in BMJ Mental Health, All-cause and suicide mortalities among adolescents and young adults who contacted specialised gender identity services in Finland in 1996–2019, analyzed overall mortality and suicide mortality among gender-referred young people in Finland over a 25-year time span (n=2,083; median age 19 years; median follow-up 5.7 years). The study defined young people as those referred to gender services under the age of 23.

The World Health Organization issued an update on its plan to develop guidelines for "trans and gender diverse people." This Spotlight shares additional analysis of the WHO guideline development process and raises new concerns.

Update: On January 15, 2024 the World Health Organization (WHO) issued a new announcement, extending the public comment deadline regarding its planned "trans and gender diverse" guidelines to February 2, 2024.

The Netherlands, like the rest of the Western world, has experienced an unprecedented increase in the number of youth seeking to undergo gender transition. Like the rest of the West, this sharp increase has been driven largely by adolescent females.

Like all medical interventions, “gender-affirming” interventions are associated with a range of physical and mental health outcomes—both positive and negative. Regret and detransition are examples of negative outcomes. Proponents of youth gender transition assert that rates of regret and detransition are extremely low.

A major medical journal Ugeskrift for Læger,  the Journal of the Danish Medical Association, confirmed that there has been a marked shift in the country’s approach to caring for youth with gender dysphoria. Most youth referred to the centralized gender clinic no longer get a prescription for puberty blockers, hormones or surgery—instead they receive therapeutic counseling and support.

Recent research published in JAMA Surgery evaluated satisfaction and regret among individuals who had undergone chest masculinizing mastectomy at the University of Michigan hospital. The average patient age at the time of mastectomy was 27 years; no patients who were under age 18 were allowed to participate in the study.

We welcome the American Academy of Pediatrics (AAP) decision to update treatment recommendations for gender dysphoric youth based on the results of a systematic review of evidence the AAP plans to commission. This is an important step on the path to creating evidence-based treatment recommendations for managing youth gender dysphoria in the United States and Canada.

A recently published study from Denmark compared the rate of suicide attempts, suicide-related deaths, non-suicide-related deaths, and all-cause mortality between non-transgender and transgender-identifying individuals. The study spanned 42 years, however the average follow-up for transgender-identified individuals was less than six years. The study found that transgender-identifying individuals in Denmark had significantly elevated rates of all four adverse outcomes.

In a new peer-reviewed commentary published in the Journal of Sex & Marital Therapy, author, Dr. Sarah Jorgensen, argues that the medical community has a professional responsibility to recognize detransitioners as survivors of iatrogenic harm and provide them with the comprehensive medical and supportive care that they deserve.

UPDATE 11/18/2023: Following a retraction by Springer, the research was re-published by the Journal of Open Inquiry of the Behavioral Sciences (JOIBS). The research underwent a new peer-review process, which resulted in some changes to the manuscript originally published by Springer. 

A new peer-reviewed article, “Transition Regret and Detransition: Meaning and Uncertainties," published in the Archives of Sexual Behavior, reviews clinical and research issues related to transition regret and detransition.

A new article in Springer’s Current Sexual Health Reports, “Current Concerns About Gender-Affirming Therapy in Adolescents,” provides an up-to-date overview of the current state of evidence about the practice of gender transition in youth in the Western world and discusses the international debates surrounding this controversial practice.

Prisha Mosley was 17 when she was first given testosterone in a clinic in North Carolina, after she had declared to her parents that she was a boy. She had struggled through her teen years with anorexia and depression after a sexual assault. Luka Hein had both breasts removed as a 16-year-old in Nebraska. Chloe Cole, in California, was a year younger when she had her double mastectomy. She had been on testosterone and puberty-blocking drugs since 13, also after a sexual assault.

A new study examining 1,655 parental reports lends further credibility to the rapid-onset gender dysphoria (ROGD) hypothesis, first posited by Dr. Lisa Littman in 2018.

A recent study published in The Journal of Sexual Medicine reported demographic and treatment trends among gender-dysphoric youth seeking evaluation and/or treatment at the Netherlands’ largest pediatric gender clinic in Amsterdam (VUmc) between 1997 and 2018.

A new open-access publication focuses on the two Dutch studies that gave rise to “gender-affirmative” care for youth worldwide, identifying profound problems and drawing the "gold standard" into question.

2022 has been nothing short of remarkable for the field of youth gender medicine. Two leading countries in pediatric gender transition, England and Sweden, stopped or announced the intention to stop transitioning youth as routine medical practice. And just as the year was drawing to a close, on December 30, 2022 a leading Dutch newspaper published the first-ever critical commentary focused on the Dutch gender clinic itself, questioning its continued support of medical interventions of the rapidly growing numbers of youths seeking gender transition.

A recent publication examines and refutes several key assumptions that underlie an influential “pro-affirmation” paper published by the journal Nature.

To what extent are the purported short-term psychological benefits of “gender-affirming” care, reported by some recent studies conducted by pediatric gender clinics, due to the placebo effect, rather than the hormonal and surgical interventions themselves? This question is the focus of a new tour-de-force peer-reviewed publication in the Archives of Sexual Behavior by Dr. Alison Clayton.

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.

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.

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

A recent study published in Pediatrics examined the five-year gender identity development trajectory of trans-identified children who underwent early social gender transition. 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. 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.

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 using psychotherapy rather than pharmacological and surgical interventions.

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. 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. 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?

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.

New systematic reviews reveal 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.

Individuals suffering from gender dysphoria 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. 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.

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