Studies

A recent retrospective, uncontrolled chart-review 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.

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.

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 transgender people.

This study, from the departments of adolescent medicine and pediatric endocrinology at the Riley Hospital for Children in Indianapolis, examines indices of mental health in GD youth after initiation of PB, following them for 12 months. It also assesses mental health measures of the primary caregivers. Eligible youth had to have reached Tanner stage 2 of puberty, with no prior history of PB use, and no plan to initiate cross-sex hormones (CSH) within 12 months of starting PB. Of the 28 patients initially considered eligible, only 16 remained eligible at the 12-month mark, due to unexpected early progression to CSH or dropout. In the final sample (n=16), the youth and their caregivers were overwhelmingly female (75%) and the mean age to start PB was 12 years.

The young patients and their caregivers completed validated questionnaires from the Patient Reported Outcomes Measurement Information System and the National Institutes of Health Toolbox at baseline, 6 months, and 12 months. Patients completed self-report measures of anger, anxiety, depressive symptoms, psychological stress experiences, and life satisfaction. Caregivers completed proxy-report measures of their child’s anxiety, depressive symptoms, and life satisfaction, as well as self-report measures of their own anxiety, depression, and perceived stress.

In the study abstract, the conclusion states that youth with gender dysphoria "experience more challenges related to psychological well-being compared to the general population" but emphasizes that "psychological well-being remained stable throughout the study." We see several important aspects of the study that are not captured by these conclusions. We discuss them below:

• Youth's self-reported mental health remained within average range throughout the study. The data indicate that most mean T-scores fell within the average/ ‘normal limits’ range for the general population according to patients’ self-reports.
• Mental health did not improve. Based on self reports, gender-dysphoric youth began the study with slightly worse functioning on measures of psychological stress and life satisfaction compared to the general population. After 12 months on PB, these measures showed no improvement, and two additional indicators—anger and depression—worsened relative to the general population.
• Parents rated the youths' mental health worse than the youth themselves. Almost all the parental assessments of children's anxiety, depression, and life satisfaction were considerably worse than the children's self-assessment. The parents in the study themselves had worse anxiety levels than the general population at all time points and higher levels of depression at baseline.
• High rates of use of psychiatric medications in PB youth. At baseline, 44% of the final participant sample were prescribed psychiatric medications, most commonly SSRIs. This proportion is considerably higher than rates observed in the general population; the CDC reported that in 2019, only 10.9% of 12- to 17-year-olds had taken mental health medications within the previous 12 months.

The study of 16 cases is too small to draw any reliable conclusions and should not be over-interpreted. However, since it's described as a "pilot" study—which suggests that it may give rise to future studies—it's worth noting some key limitations at this stage, so they can be avoided in the future. They include:

• Significant loss of study participants. Within 12 months, 43% (12/28) no longer met inclusion criteria—6 initiated cross-sex hormones and 5 were lost to follow-up—despite the researchers selecting participants expected to remain on PB without starting CSH. This substantial loss jeopardizes validity, as dropouts and early CSH initiators may differ psychologically from those who completed PB mono-therapy.
• GD levels were not assessed. Despite the fact that a primary goal of gender-affirming interventions is the amelioration of GD, the study did not attempt to measure GD at any point. Body satisfaction was also not assessed.
• Psychiatric medication use and psychotherapy represent an uncontrolled confounder. Despite the high rate of psychiatric medication use reported as baseline, the authors provide no data on psychiatric medication use at the 6- or 12-month follow-up assessments. They also omit details regarding psychotherapy use, making psychiatric medication and psychological treatment unmeasured confounders in this study.

SEGM comment: Gohil et al.’s framing of unchanged mental health as “no change,” and their selective citation of studies claiming benefits of PB (e.g., the flawed Kuper et al., 2020; and Tordoff et al., 2022) while omitting systematic reviews finding no credible benefits, mirrors the “spin” seen in other clinic-origin studies struggling to account for null results (e.g., Olson-Kennedy et al., 2025; and Carmichael et al., 2021). At the same time, there appears to be growing acknowledgment that PBs may not be a neutral intervention and that decreases in sex-steroid concentrations resulting from initiation of PB later in puberty may have negative effects. The study adds to the growing body of evidence that PB are not an effective mental health treatment for GD youth.

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.

In her paper, British clinical psychologist Anna Hutchinson, drawing on the Cass Review’s recommendations, describes a respectful, developmentally informed, and holistic psychotherapy model, grounded in transdiagnostic psychotherapy principles, that can be used for gender-distressed youth.

Hutchinson emphasizes that children and adolescents presenting with gender distress or with a transgender identification are heterogeneous. However, the gender-distressed child or adolescent does not differ from any other child or adolescent in their broad developmental, emotional, or cognitive capacities, hopes, and needs, and the therapist should approach the child with this in mind.

Hutchinson highlights that social and clinical narratives shape young people’s understanding of their identity, as well as what might best help them. She notes that although we may have inborn predispositions, it is impossible to be born with a complex social identity. Rather, our sense of self—our complex identity—develops over time and is responsive to biological, psychological, and social factors. Importantly, adolescence and childhood are times when identity is uncertain and fluid, and identity exploration is normal. Although some aspects of identity may endure into adulthood, no one (neither child, parent, nor therapist) can predict with certainty which aspects might do so, and all must sit with the uncertainty rather than rush prematurely to claim knowledge of the long-term trajectory. This understanding of identity development is core to all therapeutic approaches when working with children and adolescents.

The Cass Review emphasized that psychotherapists need to approach gender-distressed children and adolescents in the same way as they would any other distressed minor—the gender-distressed child/adolescent should not be exceptionalized. Hutchinson reminds therapists that they already have the general training and expertise to guide their clinical practice. However, knowledge specific to gender related distress is also required—the therapist needs to understand the debates in this field, how the NHS came to routinely provide medical transition to children and adolescents in the past, and why the Cass Review could not recommend its continuation.

As per standard practice therapists should undertake a comprehensive biopsychosocial assessment. Hutchinson highlights that the Cass Review recommends both diagnosis and individualized formulation when working with gender-distressed children and adolescents. However, a diagnosis alone of gender incongruence or gender dysphoria is of limited clinical utility because it has no explanatory power or predictive validity.

Thus, the individualized clinical formulation is of paramount importance; it synthesizes all available information, including the diagnosis and the hypotheses about the reasons for the person’s reported distress. Ideally, it is developed by the clinician in concert with the child and parent and it guides the individualized clinical approach. Hutchinson writes that psychotherapists need to respect individual identities, but also acknowledge the inherent uncertainty of identity development. Thus, it is important that they create an environment that sits with this uncertainty and allows for a diverse range of outcomes. It is also critical that psychotherapists be honest and engage openly with children and adolescents, and their parents, about the knowledge gaps and differing perspectives on gender distress and the optimal management approach.

SEGM comment: Due to the lack of evidence of benefits and increasing evidence of harms, many international jurisdictions now recommend psychotherapy and other psychosocial supports as first-line (or the only) interventions for young people. However, more information is required about these approaches. Anna Hutchinson is a therapist with extensive experience working with gender-distressed children and adolescents and previously worked for many years at England’s GIDS. Her paper outlines a thoughtful and respectful psychotherapeutic approach grounded in the basic principles of psychotherapy that can be applied transdiagnostically. Hutchinson helpfully highlights the vital role of clinical formulation. She also explains that ethical psychotherapy is not conversion therapy: it does not aim to change a person’s identity and, at all times, respects the developmental process and the uncertainty inherent in identity during childhood and adolescence.

As Cass has noted, there is a lack of evidence for psychotherapy as a treatment modality for gender-distressed children and adolescents, but there is strong evidence supporting psychotherapy as a treatment for various mental health conditions that frequently co-occur with gender-related distress. Cass has called for more research into psychosocial approaches for children and adolescents with gender distress.

Hutchinson’s paper is timely in the U.K., where services are transitioning away from specialized services that offered gender-affirmative treatment toward models that prioritize psychosocial interventions delivered by local services. It should also be useful for other jurisdictions that are replacing models that prioritized pediatric medical transition with those that focus on psychosocial interventions.

This study assessed long-term sexual satisfaction and dysfunction among 70 individuals who began puberty suppression (PS) at the Amsterdam gender clinic between 1998 and 2011, selected from an original cohort of 145. All participants later initiated cross-sex hormones, and many underwent genital surgery. At an average of 14 years after PS treatment (average age 29), participants completed a questionnaire on sexual experiences.

The authors compared individuals who began PS at earlier puberty stages (Tanner stage 2 or 3) to those who began later (Tanner stage 4 or 5), reporting no differences between the groups. They also compared outcomes to those who transitioned in adulthood without PS, as well as to general population data on sexual function in the Netherlands.

On the basis of these comparisons, and despite the high rates of sexual problems reported in the study, the authors conclude that PS does not negatively impact adult sexual functioning. In a press release titled “Puberty blockers do not cause problems with sexual functioning in transgender adults” they assert that there was “no difference between people who started puberty blockers early or later in puberty,” and that sexual satisfaction in the PS group was comparable to people who had transitioned as adults and the general population.

SEGM analysis: The impact of early puberty suppression on long-term sexual function is one of the most urgent ethical concerns in the debate over pediatric gender transition. A finding that PS has no adverse effect on sexual function would be welcome news to the tens of thousands of families worldwide weighing this intervention. However, this conclusion is undermined by numerous serious methodological limitations in the study, which raise significant doubts about the trustworthiness of the conclusions.

• Lack of analysis of early PS outcomes (Tanner stage 2): Only 5 participants began PS at Tanner stage 2 (early puberty), making it impossible to analyze their outcomes separately. Instead, their data were merged with those who started PBs at Tanner stage 3 (mid-puberty, n=12). As a result, the study does not provide meaningful insight into sexual outcomes for youth who begin suppression at early puberty—despite puberty blockade at Tanner stage 2 being the standard protocol in current clinical practice, and the question at the center of current debates.
• Underpowered sample unable to detect differences between early vs late PS: Even after combining participants who began puberty suppression at Tanner stage 2 or 3, the sample size (n=17) is still too small to meaningfully compare rates of sexual dysfunction with those who began at Tanner stage 4 or 5 (n=53), particularly once divided by sex. As a result, the study lacks sufficient statistical power—meaning that even if real differences existed between subgroups, the sample was too small to detect them. Further, the small sample also leads to questionable and counterintuitive results. For example, 58% of natal males who began puberty suppression at later stages (Tanner stage 4 or 5; n=12) reported difficulty achieving orgasm, compared to 0% of those who began at early-to-mid puberty (Tanner stage 2 or 3; n=8). Short of a plausible explanation for such a counterintuitive result, it raises serious concerns about the validity of the question, the representativeness of the sample, and the reliability of the results.
• Flawed measurement tool weakens conclusions about comparable sexual function: The study relied on a “partly self-created” questionnaire to assess sexual dysfunction, which has major limitations. For example, it asked whether participants had ever experienced sexual problems, without specifying when the issues occurred. Because all participants received cross-sex hormones and many also had genital surgery, it is impossible to know whether any dysfunction was due to puberty blockers, hormones, surgery, or occurred later in life. Additionally, the tool did not include pain—despite it being a common issue in transgender populations and a standard component of sexual dysfunction definitions in comparison studies the authors themselves used (e.g., Kerckhof et al., 2019; van der Meulen et al., 2024).

• Misleading comparisons to general population data: The study appears to have selectively cited sources to support its claim that high rates of sexual problems in transgender population (including those who underwent PS ) are comparable to the general population. For example, it cites a 42% dysfunction rate in a population survey of young Dutch women under 25 to suggest the PB group’s outcomes aren’t unusual—but that figure reflects any past orgasm difficulty, not distressing dysfunction. A more appropriate measure from the same survey—aligned with the study’s own definition of sexual dysfunction as requiring distress—would have been 9% (de Graaf et al. 2024a, table 4.13.1). Additionally, the cited survey participants were younger (<25 years) than the study's sample, whose average age was 29. Further, survey data from adult Dutch populations from the same agency (Rutgers) are available and point to a markedly different conclusion: that the sexual functioning in the PS sample is much worse than that in the general population. Assuming—as the authors do—that participants reported recent sexual dysfunction, the reported rates of at least one sexual dysfunction in the PS-group (50% of natal males and 58% of natal females) are much higher than reported in the general Dutch population of similar age (7% of males and 17% of females, de Graaf et al., 2024b, Table 8.1.4).

  The same population survey found that 57% of Dutch men age 25+ were satisfied with their sex lives (de Graaf et al., 2024b, p. 60) compared to just 40% of natal males in van der Meulen’s study. Further, this population survey directly compared sexual problems in transgender vs general populations, finding the former to have far less sexual frequency, more sexual dysfunction, and subjected to more sexual violence (de Graaf et al., 2024b, tables 4.3.1, 4.3.3), as did the population survey cited by the authors (de Graaf et al., 2024a, tables 3.3.1 and 3.3.3)

• Internal inconsistencies: Although it is unclear why the authors chose to rely on a less applicable survey of Dutch adults <25 to make the claim of comparable sexual function between transgender and general populations, when a more relevant survey of Dutch adults’ sexual functioning issued by the same agency was available, the authors assertions of “comparable” function are contradicted by the very sources they themes cite. For example, in the Discussion section on sexual satisfaction, they claim that satisfaction levels in their PS cohort were “comparable to or slightly higher” than other transgender cohorts that began treatment in adulthood. However, only two sentences later, they cite “systematic reviews” showing that “64%–98%” of transfeminine individuals reported being very satisfied following vaginoplasty. In contrast, their own study found that only 40% of transfeminine participants (all but one of whom had undergone vaginoplasty) reported sexual satisfaction.

  Further, a study by Rosen (2000), cited by the authors themselves, found that in the general population, orgasmic disorder rates are under 10% in males aged 18–59, yet they reported that 35% of young adult natal males who underwent PS had difficulty achieving orgasm. Thus, the authors’ conclusions of similarities in sexual function between PS and all other groups are not supported by the very data they cite.

• High dropout rate: The study had an overall participation rate of only 48%, with an even lower response rate of just 32% among male-to-female participants. The markedly high dropout rate overall and among the male participants in particular raises concerns about non-responder bias: those who responded may not accurately represent the treated population”
• Capacity for informed consent: Finally, the study does not address a key ethical issue: the profound difference in capacity for informed consent between an adult and a child as young as nine. The potential for irreversible loss of sexual function underscores the need for extreme caution—particularly given the developmental immaturity of children initiating these interventions. It is likely that a number of participants lacked any pre-PS sexual experiences and have a limited understanding of normal sexual function, questioning the validity of self-reported outcomes.

SEGM comment: The findings of this study are far from reassuring. Participants who underwent puberty suppression (PS) reported high rates of sexual dysfunction compared to the general Dutch adult population—a highly relevant population survey the authors overlooked. Although comparisons across studies with differing methodologies must be interpreted cautiously, these results challenge the authors’ conclusion that PS—regardless of timing—is not associated with future sexual health problems.

Critically, the study’s significant methodological limitations prevent any firm conclusions about whether, or how, the timing of PS influences these outcomes. The disproportionately high dropout rate among male-to-female participants raises further concerns about the outcomes of PS in natal males, and whether this attrition reflects more adverse effects in this subgroup.

Finally, the study fails to address a key ethical issue: the profound difference in capacity for informed consent between an adult and a child as young as nine. The potential for irreversible loss of sexual function underscores the need for extreme caution—particularly given the developmental immaturity of children initiating these interventions.

This study reports the results of a cross-sectional U.S. and Canadian survey that evaluated the care experiences of individuals who underwent an initial gender transition but later detransitioned. "Detransition" was broadly defined as having ever stopped, shifted, paused, or reversed an initial gender transition, or having desired detransition but feeling unable to do so. The "initial gender transition" did not require medical interventions, and could be limited to social or legal transition only. Individuals who "retransitioned" (i.e., resumed gender transition) after a period of detransition were also eligible to participate.

This study is part of the broader DARE (Detransition Analysis, Representation, and Exploration) initiative described as led by LGBTQ+ researchers. The authors claim that the hallmark of the study is its recruitment strategy, which aimed to attract not only individuals who detransitioned due to an internal identity shift, but also those who felt forced to detransition, still identified as transgender, and/or resumed their transitions. The DARE sample was comprised of 957 participants age 16+, at least 75% of whom came from social media recruitment. The sample (as described in this paper and in MacKinnon et al. (2025)) had the following composition:

• Age: The median age was 24. The single largest group was 18–24 years old (43%), followed by 25–29-year-olds (25%); fewer than 2% were age 50+.
• Sex: 79% were female.
• Detransition identification: 41% considered themselves as “detransitioned.” About the same number, 4 in 10 (40%) chose not to describe themselves as “detransitioned.” Approximately 2 in 10 (10-18%) were unsure. About 4 in 10 (42%) said they retransitioned following detransition.
• Current gender identity: 20% identified as “cisgender”, 43% identified as transgender, and 33% as nonbinary.
• Sexual orientation: More than half (57%) reported a sexual minority identity. Reported sexual orientations included bisexual (45%), queer (29%), lesbian/homosexual (27%), and gay/homosexual (10%). It is unclear whether participants reported their sexual orientation relative to sex or gender identity.
• Sexual orientation/identity change: Specific to sexual orientation and gender identities, participants reported an average of 4.2 gender identities/expression labels across their lifespan.

The Rackliff et al. study is the second publication from the DARE project, reporting on the 957 participants' responses to a set of quantitative questions, and a subsample of 563 respondents' answers the the open ended question: "Were there any supports you wish you could have had during your detransition?" The key findings are presented below:

• Social strain related to detransition: Loneliness, rejection, and isolation from previous "LGBTQ2S+" connections were “notable” among individuals who have experienced detransition. Some also reported losing family support after detransition. Of the 563 participants who answered the qualitative question, nearly 30% reported needs around more community support, and 22% reported more need for interpersonal support (see study Table 4).
• Lack of technically competent healthcare: More than 4 in 10 participants (43%) reported that providers “never” appeared knowledgeable when discussing detransition (see study Table 3). A lack of medical information (11%), especially regarding protocols for discontinuing hormones, was mentioned as a key gap. There were also unmet needs related to detransition procedures (5.5%) including surgical reconstruction, and a lack of appropriate mental healthcare and support (16%) (see Table 4).
• Lack of culturally competent healthcare: While some felt comfortable in "gender-affirming" settings, others described negative experiences, such as feeling judged, shamed, and pressured to retransition.
• Care avoidance behaviors: During detransition, nearly 6 in 10 avoided healthcare providers when they needed care (13% “always” avoided and 45% "sometimes” avoided healthcare providers, see study Table 3).
• Significance of involuntary detransition: More than 4 in 10 (42%) of DARE participants retransitioned following detransition. The authors report that “many” participants said they would not have detransitioned if affirming support had been present during their initial transition, and predict that the rate of involuntary detransitions will likely increase.

The study’s strengths include recency of sample recruitment, a rigorous strategy used to remove malicious responses, and a large sample size with diverse representation of detransition experiences. Paradoxically, a key limitation of this study arises from it’s effort to capture diverse detransition experiences. By combining two markedly different populations—primary/core detransitioners, whose detransition was motivated by an internal cessation in transgender identity, and individuals whose detransition was driven by external factors—the research might have obscured important distinctions between these groups. As a result, the reported needs and experiences might not accurately reflect either population.

There are also a number of other limitations:

• Question framing bias: The qualitative findings, which constitute the bulk of the paper, are based on responses to a negatively framed question: “Were there any supports you wish you could have had during your detransition?” In asking what forms of helpful support were missing, the study potentially failed to capture information about the helpful forms of support that were present, thereby limiting understanding of what type of support should be provided to detransitioners more generally.
• Vague reporting of results: Key findings are reported with ambiguous descriptors such as “many,” “some,” and “only a few,” making it difficult to assess the magnitude of the effects and introducing considerable uncertainty into the paper’s conclusions. For example, the authors state that “many” say they would not have detransitioned if they had had proper support; at the same time, Table 4 lists the percentage of those who said that their detransition could have been prevented by better access to gender-affirming healthcare, financial, social, or mental health support, as ranging between 4%–9%. The authors do not provide an aggregate percentage of how many endorsed "any" of the above factors, but the statistics that are shared suggest a smaller effect than the adjective "many" implies.
• One-sided commentary: There are several examples of unbalanced discussion. For example, the authors frame restrictions on pediatric transition as inherently problematic and leading to future forced detransitions, without discussing the alternative possibility that such restrictions may also decrease detransition rates by avoiding premature/misguided early transitions. There is also evidence of selective quoting of the literature, with the authors referencing Gelly et al. (2025) to support the narrative of the “weaponization” of detransition to impose legal restrictions on youth transitions, while failing to reference numerous documented counterexamples of detransitioners publicly advocating for such policy restrictions.

SEGM comment: This publication represents an important contribution to the study of the complex topic of detransition, adding an explicitly "gender-affirming" dimension to the topic. At the same time, the study has significant limitations arising from potential biases in the sampling strategy and the survey design. Any discussion of detransition findings should be tempered by the reality that the field of detransition research is in its infancy, and—like the phenomenon of transition—detransition is also socially mediated. Societal views of sex and gender identity, and knowledge of the risks, benefits, and uncertainties of transition, are evolving quickly, alongside corresponding shifts in medical, educational, and legal policies. These moving targets introduce substantial complexities that limit interpretation and warrant caution in drawing firm conclusions.

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.

The Sullivan Review was commissioned by the U.K. Government (via the Department for Science, Innovation and Technology) in October 2023. The Review was led by Professor Alice Sullivan, a sociologist at University College London. Part 1 of the Review (published in March 2025) explored the quality and nature of the data being collected for official U.K. datasets over time, finding that sex-based data is increasingly being erased or made unreliable by being combined or replaced with gender identity data. It highlighted serious implications for U.K. society and governance. Part 2 of the Review was published in July 2025. It explores the challenges faced by those researching sex and gender within U.K. institutions, which affect our ability to collect data and improve understanding within the field.

To meet its aims, Part 2 of the Review examines a range of existing public evidence such as governmental legislation and institutional policies, and conducted a public call for evidence from members of the academic community. For this evidence, it welcomed submissions from students, academics, and other staff, representing a range of experiences and views. It also included in-depth case studies of recent high-profile cases, such as Kathleen Stock.

A wide range of barriers was found to be impeding rigorous scholarship within the field. Although the report found the environment to be unpleasant for many researchers across the ideological spectrum, it identified an imbalance in the level and nature of barriers faced by researchers based on their personal beliefs. It found that gender-critical researchers faced barriers that were significantly higher in frequency and seriousness than other individuals.

Overall, the barriers explored within the report were categorized as:

• Self-censorship
• Bullying, harassment, and ostracism
• Barriers to publication
• Barriers to data collection
• Barriers to holding events
• Institutional policies and training
• Complaints, including coordinated complaints
• Management behavior
• Barriers to career progression
• Research ethics processes
• Compelled speech
• No-platforming and discrimination against speakers
• Student experiences
• Barriers to research funding
• Discrimination by administration or services
• Disinvitations from projects or collaborations

Sullivan emphasized that the core problem is not disagreement itself but hostile behavior that undermines the norms of scholarly exchange. While often carried out by a vocal minority, the impacts are far-reaching, silencing inquiry and narrowing the scope of permissible debate. It also highlighted the role that institutional policies and processes can play in perpetuating harassment and discrimination.

Ironically, the Review itself also faced attacks, with a section of the report detailing coordinated efforts to undermine the project.

The report provided 20 recommendations for future directions to improve academic freedom protections, highlighting the role of individuals, institutions, and national legislation. The recommendations focus on the government and universities, but the authors clarify that they are “also relevant for organizations outside higher education that are involved in research, in particular the NHS.”

One of the examples presented in the review is a “call to action” directed at the Royal College of Psychiatrists. The activists identified speakers that, among other things, had collaborated with SEGM or participated in our conferences. They also urged Hilary Cass and other keynote speakers “to consider whether they wish to be associated with the dangerous ideologies and practices of groups such as SEGM and CAN-SG.”

SEGM comment: Part 2 of the Sullivan Review shines a light on dynamics many clinicians and researchers in the field of sex and gender medicine will recognize. The chilling effect described here mirrors the challenges faced by many when conducting and publishing evidence-based work, particularly for those who are perceived to hold or express gender-critical views. It also highlights the concerning and inappropriate power that activism currently wields within many academic and publishing institutions, affecting their policies and papers and thereby influencing the scope and availability of much needed research. Sullivan’s report underscores a crucial truth: rigorous science depends on open debate and the freedom to pursue questions wherever the evidence leads. Policymakers, funders, and academic institutions should take note—removing barriers to research is an academic and public health necessity.

In her paper, Riittakerttu Kaltiala, head of Finland’s Child and Adolescent Psychiatric Services, outlines the Finnish approach to gender dysphoria (GD) in minors. Kaltiala provides an overview of the development of youth gender services in Finland, which initially aligned with the gender-affirming approach as set out in international guidelines.

However, Finnish clinicians quickly identified notable discrepancies between the demographic and clinical characteristics of minors presenting to their gender clinics and those documented in the existing literature. Specifically, they noted a higher number of adolescent female referrals, many of whom lacked a clear history of childhood-onset gender dysphoria and exhibited significant psychiatric comorbidities. Moreover, they found that, for a substantial number of minors, the anticipated benefits of medical gender reassignment (MGR) failed to materialize: hormonal gender reassignment did not resolve the existing psychiatric treatment needs or result in enhanced functional outcomes.

COHERE Finland is responsible for Finnish public health services. In the process of developing guidelines, COHERE commissioned systematic evidence reviews, conducted ethical assessments, and consulted various stakeholders. A 2019 systematic review commissioned by COHERE found that the evidence supporting medical interventions in minors with sex discordant gender experience and related distress was very weak. Kaltiala writes that the evidence base for MGR in minors—both the originally intended target group (as outlined in the Dutch protocol) and newly emerging patient populations—is insufficient, and the intervention should be considered experimental.

Kaltiala details some of the research that she and her colleagues have undertaken and published over the last decade. Importantly, their recent research found that suicide mortality among adolescents with GD, although elevated compared with general population statistics, is rare and is associated with severe psychiatric morbidity rather than GD itself. They also found no evidence that suicide mortality differed between GD patients who underwent MGR and those who did not.

Importantly, Kaltiala highlights that “promoting medical GR by arguing that adolescents with GD face a high suicide risk without treatment—and that GR would alleviate this risk—is ethically problematic. Such messaging may pressure parents into pursuing medical GR prematurely, even if they have concerns about the stability of their child’s gender identity or the safety of medical intervention.”

In Finland, the current clinical approach to minors with GD follows standard child and adolescent psychiatric procedures, with local services conducting a comprehensive assessment. For adolescents, the first-line treatment for GD is exploratory psychotherapeutic intervention within local services, appropriate treatment of any psychiatric comorbidities, and management of child welfare needs. Subsequently, a referral to the centralized gender identity service (GIS) may be made. If strict criteria are met, then medical intervention may be initiated. Kaltiala notes that, since 2021, the number of referrals to GIS has plateaued, but most referrals are still adolescents with severe psychiatric comorbidities and significantly impaired functioning. Thus, the approach to medical gender reassignment during the developmental years has become more cautious.

SEGM comment: In response to Finnish clinicians recognizing deficiencies in the evidence base, changes in demographics, and clinical features of minors referred to the GIS, and their own research demonstrating a lack of benefit from medical transition, Finland became the first European country to move its national treatment model for minors with GD away from the gender-affirming approach as outlined in the Dutch Protocol and WPATH guidelines and toward an evidence-based treatment pathway that prioritized psychosocial support and psychotherapy. For the same reasons, many other countries are now following suit. Thus, this paper provides a helpful guide for other countries’ health services as they grapple with developing new treatment models.

Last May, the United Nations published the report “A/HRC/59/47: Sex-based violence against women and girls: new frontiers and emerging issues”, authored by Reem Alsalem, Special Rapporteur on violence against women and girls, to be delivered at the 59th session of the Human Rights Council.

The report analyzes new and evolving forms of violence against women and girls and proposes recommendations to address them. Like Sullivan and her team, Alsalem warns that some countries and institutions have replaced or conflated “sex” with “gender identity”, and highlights that collecting accurate sex-based data is “essential to evidence-based policymaking across sectors, from healthcare to criminal justice.” Moreover, the Special Rapporteur notes the emerging tension between the obligation of States to foster equality and the evolving concept of gender identity. According to the report, sexist stereotypes are directly related to different forms of violence against women and girls. These stereotypes, however, are sometimes framed as "true manifestations of gender identity."

Notably, the report expresses concerns about gender dysphoria and medical transition for minors, stating that emerging evidence of long-term harms “has rightly led several countries, such as Brazil, the Kingdom of the Netherlands and the United Kingdom to change course and restrict children’s access to puberty blockers, cross-sex hormones and surgery on sexual and reproductive organs.” The author also argues that children are “not able to provide informed consent for such procedures.”

Alsalem makes the following recommendations regarding medical transition for minors:

• Prohibition of social, legal, and medical transition in minors
• Creation of laws and policy that provide remedy, accountability and support for those affected, including detransitioners.
• Funding of special support services for vulnerable girls to address “heightened risk of bodily dysphoria and bodily dissociation.”

SEGM comment: Alsalem links medical transition for minors to violence by arguing that these procedures violate children's rights to "safety, security and freedom from violence," as well as their right to the highest attainable standard of health. This framing positions medical transition of minors as a human rights issue related to protecting children from harm, which explains its inclusion in a report specifically focused on violence against women and girls.

We welcome the interest of a Special Rapporteur of the United Nations in the field of pediatric gender medicine. Alsalem echoes the concerns expressed by many clinicians and researchers about the long-term effects of medical transition, the prevalence of mental health comorbidities and the challenges of obtaining informed consent from minors. The report further highlights the substitution of “sex” with “gender identity” as an obstacle for the collection of accurate research data, an issue also recognized in the Sullivan Review. This report illustrates the broad implications of pediatric gender medicine and the importance of reliable evidence for medical policy.

As part of the NIH-funded Trans Youth Care US Study, pediatrician Johanna Olson-Kennedy and colleagues report on the mental health outcomes of a cohort of 94 children and adolescents (ages 8–16) who received puberty blockers (PB) for gender dysphoria (GD). The participants were recruited from four US pediatric gender clinics between 2016 and 2019. They completed various mental health rating scales at baseline, and then at six-month intervals up to 24 months.

The study found no significant change in mental health over this period, with the authors reporting that at no point did the mean scores of depression, emotional health, and the parent-rated Child Behavior Checklist (CBCL) constructs reach a clinically concerning range. A substantial minority had moderate to severe depression scores both at baseline (18%) and at the 24-month follow-up (23%).

Despite the lack of improvement, the authors conclude that PB have a positive effect because “it is likely that puberty blockers prevent the deterioration of mental health”.

SEGM analysis: This study has been published as a pre-print and is not yet subject to peer review. However, the version made publicly available suggests serious methodological limitations. It makes misleading conclusions while adding little to our knowledge—we still do not know if PB are likely to improve, worsen, or have no impact on the short-term mental health of young people presenting with gender dysphoria. In addition to the well-described problems with a lack of control groups in much of pediatric gender medicine research, further problems in the study include:

• Sample selection bias. The study subjects had high mental health functioning at baseline —unlike typical gender clinic populations, where over 70% report serious pre-existing mental health issues. According to the study protocol, patients (or parents) with “serious psychiatric symptoms” or who were “visibly distraught” were excluded. Although the study does not provide data on how many of the patients treated at the participating clinics were excluded from the study or why, the protocol criteria and the makeup of the study sample at baseline strongly suggest that the study began with a highly selective, unrepresentative sample.
• High dropout rate. In addition to starting with a sample biased toward good mental health, it appears that 37% of the participants dropped out by the end of the study period at 24 months. The authors do not report this dropout rate explicitly, but it can be derived by analyzing the text and tables (the number of participants decreased from n=94 at baseline to n=59 at 24 months). High rates of dropout can mask adverse outcomes, introducing another source of bias.
• Confounding. The study makes no mention of what other interventions—including psychiatric medications or therapy—the study subjects may have received. This is despite the fact that the registered protocol indicates that psychiatric medications use by the study subject was collected. If a substantial number of youths were receiving these co-interventions, it is impossible to determine if high level of functioning at 24 months was due to PB or other interventions.
• Failure to report on key outcomes. The paper does not report on GD outcomes, despite GD being required for inclusion and listed in the protocol as an evaluation measure. The protocol underwent multiple amendments between 2017 and 2021; the UGDS gender dysphoria scale, originally a key measure, was removed in 2019 without explanation. Other scales listed in the protocol—such as body image, body esteem, and transgender congruence—are also omitted from the final report, with no justification.
• Unsupported claims about suicidality. Olson-Kennedy et al. claim that while baseline suicidality matched national rates, it was “lower than the national average” after 24 months. However, this claim is unsupported by data analysis. Table 5 shows suicidality was measured only for the prior six months at the 24-month mark, whereas the cited national study (Young et al., 2024) reports lifetime rates. Comparing short-term suicidality to lifetime prevalence is methodologically unsound, as shorter timeframes are expected to yield lower rates. This undermines the paper’s assertion of reduced suicidality.
• Misrepresentations of prior evidence. In discussing the existing body of literature, Olson-Kennedy et al. selectively cite studies, omit key limitations, and overstate the link between PB and improved mental health. For instance, they claim Costa et al. (2015) found better psychosocial functioning with PB plus therapy compared to those who had psychotherapy alone, yet Costa found no significant difference between groups. They also misrepresent McGregor et al. (2024), stating PB reduced suicidality, when in fact the study found no difference after adjusting for age and sex. Finally, they ignore studies that found no improvement or limited improvement (for a review, see McDeavitt, 2024).

SEGM comment: The authors fail to engage with study results in good faith. The study found no change in mental health after PB, yet Olson-Kennedy et al. claim it shows benefit—arguing PB prevent decline because older youth with gender dysphoria often have poor mental health. While it's true that older adolescents and adults who identify as transgender have high rates of mental health difficulties, drawing strong conclusions of benefits of blocking puberty results from a null result based on speculative comparisons is not justified. Other explanations—such as the selection criteria resulted in a sample that was already high-functioning, and had little room for improvement, or that PB have no positive effect on mental health—are more plausible. This study represents the second unsuccessful attempt to replicate the reported outcomes of the Dutch Protocol; the first failure being Carmichael et al., 2021 in the UK. The significant delay in Olson-Kennedy et al. publishing their findings—reportedly due to unfavorable results, according to the New York Times—closely resembles the pattern observed at the now-closed Tavistock clinic in the UK. The U.S. pediatric gender clinic where principal investigator Olson-Kennedy worked has now also announced its closure, effective July 2025.

Over the last two years there has been a surge in research studies and systematic reviews reporting on the use of puberty blockers and cross-sex hormones as treatment for gender-distressed youth. This makes it difficult for the non-specialist to keep on top of the evidence. The psychiatrist Kathleen McDeavitt and colleagues J. Cohn and Chan Kulatunga-Moruzi provide a comprehensive overview of the current state of the evidence underpinning hormonal treatments for children and adolescents with gender-related distress.

Two tables detail the key clinical research studies on safety/risks and effectiveness/benefits. A third table, assessing the safety/effectiveness of hormone treatments, documents the multiple systematic reviews that have been undertaken. The authors also provide a helpful summary of the principles of evidence-based medicine.

The authors conclude that puberty blockers and cross-sex hormone treatment for gender-distressed youth carry significant and inevitable risks, and that the evidence for their mental health benefits is lacking.

SEGM comment: McDeavitt and colleagues’ paper provides an excellent overview of the current literature and the state of the evidence. It will be a helpful go-to resource for anyone seeking a succinct summary of key research in this field.

Internationally, a growing number of European countries have retreated from the "gender-affirming treatment model" for children and adolescents due to concerns about a lack of evidence of benefits and increasing evidence of harms of these interventions. These developments have largely been ignored by U.S. medical bodies and health authorities. This changed with the May 1, 2025, release of the Department of Health and Human Services review into pediatric gender dysphoria.

The HHS report is divided into five substantial sections: background; evidence review; clinical realities; ethics review; and psychotherapy. This comprehensive review demonstrates that:

• Pediatric transitions were launched without proper justification. Usually, when an off-label treatment is used in pediatrics without prior clinical research, it is because it has been proven safe and effective in adults. In the case of youth transitions, the opposite has occurred: gender transitions for older adolescents were launched in response to the failures of the practice of adult transitions to deliver satisfactory outcomes, in the hope that earlier transitions would improve outcomes. The protocol was then extended to children and adolescents as young as 8–12 without scientific or ethical justification.
• The risk-benefit ratio of pediatric transition is unfavorable. Nearly 20 years after the formal introduction of the Dutch protocol in 2006, the best available evidence in the form of systematic reviews has failed to detect credible benefits. In contrast, harms, such as harms to fertility and a number of other health domains, are much more certain and arise from biological and general scientific knowledge.
• The evidence for the practice of gender transitions has been manipulated. WPATH and gender clinicians have consistently misrepresented the evidence for pediatric transition. They have also engaged in suppression of debate and disparaged those raising questions about the evidence and ethics of pediatric gender transitions. The U.S. medical establishment has delegated the assessment of the treatment outcomes to small, ideologically driven, WPATH-aligned groups and failed to engage in independent analysis.
• The U.S. medical establishment has failed to respond to new scientific information. The unfavorable risk-benefit ratio of youth transitions has led an increasing number of European countries to change their treatment approaches accordingly, prioritizing non-invasive interventions such as psychosocial support and psychotherapy. In contrast, the U.S. medical establishment has failed to respond and continues to promote pediatric transitions as the only acceptable treatment model for gender-distressed youth.
• Medical ethics supports prioritizing psychotherapy over hormones and surgery for youth. Hormones and surgery have uncertain benefits and certain harms, while psychotherapy has uncertain benefits but is not associated with known harms. Clinicians have a duty to protect patients from harm—even when harmful treatments are requested—since the principle of autonomy does not override the obligation to do no harm, particularly in the care of minors. Psychotherapy emerges as the least-harmful treatment, while efforts to conflate psychotherapy with "conversion therapy" are misguided and/or politically motivated.

SEGM comment: Despite the polarized and politicized context in which the HHS Review was commissioned, it stands as a measured and rigorous analysis of the best available evidence and ethical considerations regarding gender transition in minors. It has received favorable coverage from respected outlets such as The Washington Post and The Economist. Although major medical societies have so far avoided engaging with the Review’s findings, its credible analysis and measured tone are likely to have a gradual but lasting impact on clinical practice in the U.S. and abroad. Some cite the political climate to dismiss the Review, but its greatest challenge may simply be its length: 409 pages in the main report, with a 174-page appendix. The 4-page executive summary is useful, but the full report remains essential reading for anyone personally or professionally involved in this field.

Endocrinologist Michael Laidlaw, along with obstetrician and gynecologist Angela Thompson and Jennifer Lahl (R.N., M.A., and President of the Center for Bioethics and Culture) examine the current understandings and ethical issues surrounding fertility preservation (FP) for children and adolescents with cancer and gender dysphoria.

They highlight that FP methods used during early puberty (which can occur as young as eight in females and nine in males) are still experimental, and that there is no evidence that these methods are successful for children and adolescents who start early medical gender-affirming treatment (GAT).

The authors emphasize the difference between using these experimental FP methods in situations such as childhood cancer, where chemotherapy or radiotherapy is the only option to preserve life, versus using them for gender dysphoria. Laidlaw and colleagues point out that causing infertility or reduced fertility through medical GAT takes away children and adolescents’ “right to an open future,” especially since they cannot provide informed consent for a future loss of their reproductive function at an early stage in their development.

The authors conclude that it is unethical to cause iatrogenic infertility/subfertility in children and young adolescents through GAT and then offer experimental, invasive fertility preservation as a way to circumvent this issue.

SEGM comment: The proponents of pediatric gender transitions emphasize the importance of fertility preservation (FP). This underscores the point that the loss of fertility should be conceptualized as a key harm of the GAT treatment pathway. The early intervention model advocated by the Dutch Protocol — puberty blockers administered at the earliest stage of puberty and later followed by cross-sex hormones — greatly hinders the difficult task of successful fertility preservation due to immaturity or unavailability of the gametes (eggs and sperm). Given the anticipated loss of fertility in gender-transitioned youth, the benefits of the treatment should be commensurate. Unfortunately, no robust evidence to date has been able reliably to demonstrate psychological benefits from pediatric gender transitions.

It is widely agreed that the evidence regarding the benefits and harms of the gender-affirming treatment (GAT) model for youth is inadequate. There is currently considerable discussion on how to improve the quality of this evidence. A recent paper by Van Breukelen provides a valuable contribution to this important debate.

Gerard Van Breukelen, from Maastricht University’s Department of Methodology and Statistics, provides a detailed overview of the problems with current research methodology in youth gender medicine and offers some ideas for advancing the quality of evidence. He begins by outlining why a randomized controlled trial (RCT) is the best study design for comparing different treatments with respect to their beneficial and, potentially, averse effects on health outcomes of interest. He observes that clinicians in youth gender medicine object to RCTs on the basis of claimed ethical and feasibility issues.

He then explains why the main existing study design in youth gender medicine—a pre-post comparison of a single treated group without a control group—provides only weak evidence due to its susceptibility to many confounding factors, such as natural changes over time, regression to the mean, placebo effects, and selective dropout. Similarly, studies that have compared youth receiving GAT to youth who do not are also subject to unmeasured confounders, loss to follow-up, and are often limited by short-term follow-up only.

As a potential way to advance the evidence in this field, Van Breukelen suggests a carefully designed and conducted international, multicenter “quasi-experiment,” in which the outcomes of patients from clinics implementing medical GAT are compared with those at clinics that refrain from or restrict such treatments.

SEGM comment: This technical paper covers complex methodological and statistical principles in a way that makes them accessible to those without specific training. It is a helpful addition to the debate regarding how to improve the evidence in this field of medicine.

In this article, two Dutch legal experts (Smeehuijzen and Hoekstra) and a medical ethicist (Smids) evaluate whether the Dutch Protocol as laid out in the 2018 Dutch guideline for somatic gender care (i.e., medical and surgical interventions) meets the necessary requirements for it to have authority in legal settings be recognized as the standard of care. Of note, the 2018 Dutch Protocol substantively departed from the original Dutch Protocol by reducing lower age limits for puberty blockers, cross-sex hormones, and mastectomy, and by dropping the requirement of pre-existing childhood gender dysphoria as a condition for obtaining medical and surgical interventions in adolescence.

The authors outline the three key criteria required in the Netherlands for a standard of care to be considered legally authoritative, namely: (1) the standard is evidence-based, (2) it is not of an ethical nature, and (3) it was established through a properly designed process. They find that the 2018 Dutch Protocol fails to meet these criteria and thus conclude that courts should not rely on it.

SEGM comment: Although this article focuses on the Dutch medical and legal situation, it is likely to have considerable cross-over relevance to other countries. The 2018 Dutch protocol's criteria and development bear significant resemblance to the 2017 Endocrine Society guideline and the WPATH Standards of Care, both of which have been identified as the source of all other "affirmative" guidelines. Practitioners relying on such guidelines may find that poorly evidenced and/or inadequate medical treatment protocols and clinical practice guidelines might not be accepted as the medical standard of care in adversarial legal settings.

A new systematic review and meta-analysis, undertaken by researchers from McMaster University, addresses the evidence regarding the benefits and harms of one of the most common types of "gender-affirming" surgeries for minors—mastectomy—with a focus on psychological and physical health outcomes in the adolescent and young adult population under age 26. Miroshnychenko et al. adhered to high methodological standards for conducting systematic reviews. The authors conducted a systematic search, assessed primary studies meeting the inclusion criteria, assessed the primary studies for risk of bias using ROBINS-I, and assessed the certainty of evidence using GRADE. Whenever possible, meta-analyses were undertaken as well.

Of 39 included mastectomy studies, 3 are classified as comparative observational, 2 are before-and-after, and 34 are case series. The studies are frequently rated as being at serious or critical risk of bias (for example, due to confounding, not including all eligible participants, missing data, and outcome measurement inadequacies). Evidence for psychological outcomes (including quality of life, gender dysphoria, body and chest satisfaction, and depression) is predominantly rated as very-low certainty. Evidence for some post-operative outcomes, such as death (0/1000), necrosis (10-40/1000), and hypertrophic scarring (50/1000) is rated as high certainty. Risk of regret is assessed as 10/1000 and is rated as very low certainty.

The authors conclude that higher-quality evidence—ideally from prospective cohort studies and, where ethically feasible, randomized controlled trials—is needed to understand the impact of "gender-affirming" mastectomy on mental health outcomes. This evidence is essential to ensure that individuals with gender dysphoria, along with their clinicians, guideline developers, and policymakers, can make informed decisions.

As part of the methodological rigor of the review, the author team provided a comprehensive disclosure of interest, including the fact that the review was funded by the Society for Evidence-Based Medicine (SEGM) through a multi-year research agreement between McMaster University and SEGM. The authors detail how potential conflicts of interest (COI) were managed.

SEGM comment:

This systematic review is significant for three reasons. First, it is the first to conclude that the risk-benefit profile of youth mastectomies is unfavorable: while the harms are well-documented, potential benefits, such as reduced dysphoria or improved quality of life, remain uncertain. Second, it was conducted by a team from McMaster University, an internationally renowned center of evidence-based medicine (EBM), and the author group includes internationally recognized experts in the EBM field. Third, the systematic review was published in Plastic and Reconstructive Surgery, the official journal of the American Society of Plastic Surgeons (ASPS), the surgical specialty most often performing these procedures.

Of note, WPATH’s 2022 Standards of Care, version 8 (SOC-8) claims that 'gender-affirming' mastectomy is a safe and effective treatment and that its efficacy has been “demonstrated in multiple domains, including a consistent and direct increase in health-related quality of life, a significant decrease in gender dysphoria, and a consistent increase in satisfaction with body and appearance” (p. 128). The findings of this published systematic review directly challenge WPATH's assertions regarding the benefit and harms of mastectomy.

Given the weight of the review's findings, it is not surprising that the journal solicited additional commentaries. Foster et al. offered a positive response, praising the systematic review’s methodological rigor. In contrast, Schechter et al. offered a sharply critical response. Some of Schechter et al.’s critiques warrant further consideration and discussion, while others appear misguided. Unfortunately, Schechter and his two coauthors—all of whom coauthored the WPATH Surgery chapter—present their critiques through a sharply politicized lens, relying on ad hominem attacks to discredit the systematic review. It would be of great assistance to this debate if Schechter and colleagues authorized the publication of the WPATH commissioned Johns Hopkins systematic review of gender-affirming surgery, which, according to the court disclosures discussed in the HHS Review, have been suppressed from publication (HHS Review, p. 163).

This unfortunate approach to debate reflects a broader pattern often seen when influential figures in transgender medicine are confronted with new evidence that challenges their assumptions, beliefs, and clinical practices. In turn, this dynamic hinders self-correction within the field. Regulatory interventions—including legislative restrictions, as well as actions by medical boards and public health authorities—have become increasingly common as countries around the world work to bring gender medicine in line with the standards expected in other areas of healthcare.