The case for gender (transition) affirming therapy—which is more realistically termed gender imitating medical intervention—for gender dysphoria and incongruence is precipitously weakening. Leading its takedown are comprehensive literature reviews. These are surprisingly few, but each has led to a sea change of practice for gender dysphoria in their respective nations of origin abroad.

 

Comprehensive Literature Reviews

I will briefly identify the comprehensive scientific literature reviews before presenting what happened in their wake. These include:

• The Swedish Agency for Health Technology Assessment and Assessment of Social Services’ 2019 literature review
• The 2020 “Recommendation of the Council for Choices in Health Care in Finland (PALKO/COHERE Finland): Medical Treatment Methods for Dysphoria Related to Gender Variance in Minors;”
• From the United Kingdom’s National Institute for Health and Care Excellence (NICE) came two in 2020, considered the best of their kind:
  • “Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria”
  • “Evidence review: Gender-affirming hormones for children and adolescents with gender dysphoria”
• The 2022 Cass Review Interim Report, which is a work in progress
• The 2022 Florida Agency for Healthcare Administration’s (AHCA) Generally Accepted Professional Medical Standards (GAPMS) Determination on the Treatment of Gender Dysphoria comprehensive literature review.

 

Two honorable mentions are worth noting. One is James Cantor’s contribution to the just mentioned Florida AHCA GAPMS report, Attachment D, section II, in which he states, “Regarding pubescent and adolescent age minors, there have been (also) 11 follow-up studies of puberty blockers and cross-sex hormones. In four, mental health failed to improve at all. In five, mental health improved, but because psychotherapy and medical interventions were both provided, which one caused the improvement could not be identified. The two remaining studies employed methods that did permit psychotherapy effects to be distinguished from medical effects, and neither found medical intervention to be superior to psychotherapy-only.” The short take is provided by Leo Sapire, “In other words, the number of studies that demonstrate the superiority of hormones to psychotherapy is zero. This is why systematic reviews of the evidence by health authorities in Sweden, Finland, and the U.K. found that hormonal interventions lack adequate justification.”

 

Literature Reviews and Their Results

 

The Swedish Agency for Health Technology Assessment and Assessment of Social Services’ 2019 literature review found few studies on gender-affirming surgery in minors, few studies on long-term effects and that “Almost all” studies were observational and “no relevant randomized controlled trials in children and adolescents were found.” In April 2021, Sweden’s Karolinska Hospital and its Astrid Lindgren Children’s Hospital’s pediatric gender services issued a policy change (unofficial English translation available here). Hormonal treatments (PBA and CSH) will not be allowed under age 16. Patients 16 to 18 can only receive hormonal treatment in a clinical trial setting. Psychological and psychiatric care must continue under 18. The review warned, “These treatments are potentially fraught with extensive and irreversible adverse consequences such as cardiovascular disease, osteoporosis, infertility, increased cancer risk, and thrombosis.”

 

In February 2022, the Swedish National Board of Health and Welfare (NBHW) published “Care of children and adolescents with gender dysphoria.” The documents notes,

“For adolescents with gender incongruence, the NBHW deems that the risks of puberty suppressing treatment with GnRH-analogues and gender-affirming hormonal treatment currently outweigh the possible benefits, and that the treatments should be offered only in exceptional cases. This judgement is based mainly on three factors: the continued lack of reliable scientific evidence concerning the efficacy and the safety of both treatments [2], the new knowledge that detransition occurs among young adults [3], and the uncertainty that follows from the yet unexplained increase in the number of care seekers, an increase particularly large among adolescents registered as females at birth [4].”

 

Finland rejected the routine affirmation pathway for gender dysphoric minors in the Council for Choices in Health Care in Finland (COHERE Finland) 2020 recommendations, based on their literature review. It redirected therapy toward a strong emphasis on mental health evaluation and treatment and recognized childhood phases and fads, tasking professionals to be vigilant to investigate “…if the variation in gender identity and related dysphoria do not reflect the temporary search for identity typical of the development stage of adolescence….” The recommendations prohibit transition surgery altogether: “Surgical treatments are not part of the treatment methods for dysphoria caused by gender-related conflicts in minors.”

 

The UK’s National Institute for Health and Care Excellence (NICE) 2020 “Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria” concluded that such studies were found to be “of very low certainty using modified GRADE. They suggest little change with GnRH analogues from baseline to follow-up.” The NICE “Evidence review: Gender-affirming hormones for children and adolescents with gender dysphoria” warned that “Any potential benefits of gender-affirming hormones must be weighed against the largely unknown long-term safety profile of these treatments in children and adolescents with gender dysphoria.” It then said of existing literature study quality, “All results were of very low certainty using modified GRADE” before very significantly reporting, “Adverse events and discontinuation rates associated with gender-affirming hormones were only reported in 1 study, and no conclusions can be made on these outcomes.”

 

A United Kingdom High Court ruled in the Bell v. Tavistock case on December 12, 2020 that puberty blocking agents and cross-sex hormones were experimental with limited evidence of safety and efficacy. The case has been appealed. Within weeks, the National Health Service amended specifications for the Gender Identity Development Service (GIDS) for children and adolescents: Children under 16 can no longer be referred to pediatric endocrinology for puberty blocking agents without court order; those under 16 already on puberty blocking agents need “full clinical review” and a court order to continue or start cross-sex hormones; GIDS must ensure psychological support and therapies to both patients being removed from hormones and their families/caregivers; and for those 16 and 17 who meet the qualifications, are competent and have parental approval, “treatment may proceed,” but even then court order is advised if any doubt remains about the “best interests” of the patient.

 

The Cass Review Interim Report of 2022 led to the closing down of NHS’s GIDS, the world’s largest pediatric gender center, pending a new multi-center model with renewed emphasis on sound and documented diagnosis, psychological and social support for patient and family, particular attention to neurodevelopmental diagnoses and clear documentation of informed consent—all of which the report found to be seriously lacking. Of the many revelations in the report, the first item in the glossary on page 78 declares the “Affirmative model” to be “A model of gender healthcare that originated in the USA.” Malpractice cases against NHS’s GIDS are now lining up.

 

The NHS “Interim Service Specification for Specialist Gender Dysphoria Services for Children and Young People” was issued October 20, 2022. This new model mandates strong emphasis on mental health. Specialty teams are to be headed by pediatricians and staffed with experts on autism, neurodisability and mental health addressing “a broader range of medical conditions in addition to gender dysphoria.” Social transitioning is to be viewed as an “active intervention” that may have significant effects on the child or young person. The reality of desistance is declared and information “…will reflect evidence that in most cases gender incongruence does not persist into adolescence.” As for hormonal interventions, “NHS England will only commission GnRHa in the context of a formal research protocol.” It is thought this will likely also be true of cross-sex hormones. Finally, there must now be “adequate follow up into adulthood,” not simply ceasing to follow once the patient reaches 18 years of age.

 

Finally, Florida’s AHCA passed a rule change to exclude gender (transition) affirming (imitating) medical interventions from Medicaid payment. The scientific and professional foundation for this decision was published in June 2022 with the 233-page “Generally Accepted Professional Medical Standards [GAPMS] Determination on the Treatment of Gender Dysphoria.”[1]

 

It also referenced the fact that existing Florida Medicaid rules prohibit funding for treatments that are “experimental or investigational” (Rule 59G-1.035). The GAPMS report includes a comprehensive literature review as Attachment C. Its summary notes the literature review generally found low to very low certainty of evidence for claims of improvement from gender (transition) affirming therapy. Under puberty blockers, it found that for “most outcomes (except suicidality), there is no evidence about the effect of puberty blockers compared to not using puberty blockers.” Also, “There is very low certainty about the effects of puberty blockers on suicidal ideation.” For cross-sex hormones: “For almost all outcomes (except breast cancer) there is no evidence about the effect of cross sex hormones compared to not using cross sex hormones.” It adds, “moderate certainty evidence suggests a low prevalence of venous thromboembolism after treatment with cross-sex hormones.” For surgeries, it found: “no systematic reviews and studies reporting on gender dysphoria, depression, anxiety, and suicidality.” It further found “…very low certainty evidence about changes in quality of life after surgery.” Subsequently, the Florida Board of Medicine’s legislative committee voted on October 28, 2022 to ban transgender drugs and surgeries for minors.

 

All these comprehensive literature reviews come to the same conclusions that the body of scientific literature in support of transition-affirming medical interventions for gender dysphoria and incongruence in minors is of low to very low quality. The UK, Sweden and Finland have reversed their previous medical intervention pathway in favor of strong emphasis on the need for deep and continued mental health evaluation and treatment for both patient and family. Florida is leading the efforts to do the same in the United States. The evidence mounts that there is a more honest way to deal with gender confusion and incongruence than chemical sterilization and surgical mutilation of otherwise healthy bodied youth.

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[1] I was and remain contracted by the state of Florida to help on this project.