Experts scrutinize HHS report on gender-affirming care for minors

Key takeaways:

• HHS released a review finding significant risks and few benefits of gender-affirming care for adolescents.
• Experts told Healio they took issue with the language, methodology and conclusions of the report.

HHS published a review of gender-affirming care for minors that claimed there are significant risks associated with medical interventions and what the department called “very weak evidence of benefits.”

On Jan. 28, President Donald Trump ordered HHS to conduct a review of existing literature for treating children with gender dysphoria and publish it within 90 days. The 409-page report was published May 1. HHS did not release the names of the contributors, but a press release stated that the authors included medical doctors, medical ethicists and a methodologist.

Researchers who study gender-affirming medicine questioned the methodology of the HHS review and the language that the authors used to describe gender dysphoria and gender-affirming medical care.

Stéphanie J. Madill, PhD, an assistant professor at the University of Saskatchewan, told Healio that the authors “found what they wanted to find, very clearly.”

‘Not a clinical practice guideline’

The Williams Institute at the University of California Los Angeles School of Law estimates that more than 1.6 million people aged 13 years or older in the United States identify as transgender, including 0.5% of adults and 1.4% of adolescents aged 13 to 17 years.

Health care for transgender people has been under a microscope in the U.S., where more than half of states have passed bills restricting gender-affirming care for minors in the past 5 years, according to KFF, which reported that 40% of transgender adolescents live in these 27 states.

According to the Human Rights Campaign, some states have passed laws prohibiting the use of public funds to pay for gender-affirming care for people of any age, which affects people on Medicaid, those who work in the public sector and people who are incarcerated.

Past research has shown that transgender youth may experience better mental health after being treated with puberty blockers and gender-affirming hormones, and that transition care can saves lives. However, the authors of the HHS report performed an umbrella review of systematic reviews and reported finding a lack of quality evidence on the benefits of gender-affirming care.

“This indicates that the beneficial effects reported in the literature are likely to differ substantially from the true effects of the interventions,” the authors wrote.

They also cited risks of pediatric transition care — including osteoporosis, cognitive effects and psychiatric disorders — and argued that puberty blockers and hormone therapy can cause permanent damage to sexual organs, thereby causing permanent infertility.

The authors quoted a systematic review that argued against following guidelines from the World Professional Association for Transgender Health (WPATH) and the Endocrine Society because they “lack developmental rigour and transparency.”

The authors claimed that policies published by U.S. medical associations were influenced by WPATH and, “It is not clear that the official views of these associations are shared by the wider medical community, or even by most of their members.”

Psychotherapy was a prominent focus of the report. The authors argued that more research should delve into using psychotherapy alone to treat gender dysphoria because it is less invasive than hormones and surgical treatment. They categorized psychotherapeutic approaches to managing gender dysphoria as being unfairly maligned as “conversion therapy.”

The authors also claimed there is no independent association between gender dysphoria and suicidal ideation and “no evidence that pediatric medical transition reduces the incidence of suicide,” although studies have found the opposite to be true.

The authors stated that the report “is not a clinical practice guideline, and it does not issue legislative or policy recommendations. Rather, it seeks to provide the most accurate and current information available regarding the evidence base for the treatment of gender dysphoria in this population, the state of the relevant medical field in the United States, and the ethical considerations associated with the treatments offered.”

‘Short shrift’ to opposing views

Researchers told Healio that they took issue with the language and methodology used in the report, and several organizations that were named in the report released statements refuting the claims the authors made about transgender health care.

“They give a very short shrift to any opposing points of view. They’ve got a lot of dog whistles,” Madill said. “They put a lot of things that should be just neutral terms — like gender dysphoria and gender-affirming care — in quotation marks to make them seem like they’re new or they’re particularly political or weird when they’re not.”

“They also use some really strong language without giving examples or supporting it: things like ‘suppressed dissent’ and ‘stifled debate,’ ‘drastic interventions,’” she said.

Madill also questioned why the authors opted for an umbrella review instead of a “true systematic review.”

“An umbrella review is a systematic review of systematic reviews,” she explained. “Many of the systematic reviews contain the same original studies, and so studies that were in there more than once are being amplified, and studies that are only in there once are therefore being given less weight.”

Jae D. Corman, PhD, senior director of clinical analytics at FOLX Health, a health and wellness platform offering health care to LGBTQ+ patients, said the conclusions of the report were not based on science.

“It would certainly not pass peer review for any scientific journal because it relies heavily on anecdotes and misrepresents the state of science,” Corman told Healio.

Madill also noted the short window of time between when the review was ordered and when the results were published compared with “how long these sorts of things usually take,” which is up to a couple of years for “a true systematic review using Cochrane methods.” She also said that the methodology did not come until chapter five — much later than is typical — and that participants’ ages were ambiguous and potentially misleading.

“Part of this is because they were stuck with who was included in the systematic reviews to start with. They included youth up to age 26, and I don’t know about you, but I don’t consider a 26-year-old adolescent,” she said. “When we’re talking about children and adolescents, how many of these adolescents were 26 and how many of them were younger? That information is not available, and it makes a huge difference.”

Madill said that the report was correct in acknowledging that the strength of evidence is poor.

“There aren’t any good randomized controlled trials. That’s true for a lot of things in medicine, and particularly for medicine related to children and youth,” she said. “There isn’t a lot of research, and there isn’t a lot of long-term follow-up.”

“There is a tremendous amount of clinical experience among physicians who treat kids with gender dysphoria,” she said.

‘Not based in science’

Madill also questioned some of the risks associated with gender-affirming care that were listed in the report. For example, infertility was listed, “but just going on cross-sex hormones does not necessarily lead to infertility,” she said. A more permanent surgical transition would lead to infertility, but that is also the patient’s choice, and they have the option to freeze sperm or eggs in case they change their mind about parenting down the road, she said.

“Somebody who is assigned female at birth but who is transmasculine and who is on testosterone and is sexually active with somebody who produces sperm also has to be on birth control because just being on testosterone doesn’t guarantee — even if they’re not menstruating — that they can’t get pregnant,” Madill said. “I think it’s unfair to categorize infertility as a capital-R risk.”

Notably, some of the treatments mentioned in the report have been used for cisgender patients without controversy. For example, puberty blockers are a part of standard medical care regularly used for young cisgender girls who begin puberty at age 8 or 9 years when they “aren’t socially and intellectually mature enough to handle being sexual beings,” Madill said.

“That’s what these medicines were developed for originally. There’s lots of experience with what they do and how they work with those children; we’re just using them differently in other children, and they are 100% reversible,” Madill said.

This past year, the United Kingdom banned the use of puberty blockers to treat gender dysphoria among minors after the publication of the Cass Report, a review authored by British pediatrician Hilary Cass, MBBS, which found weak evidence of their benefits for treating gender dysphoria. Corman said the Cass Report has been “discredited and disproven.”

In 2017 guidelines for treating transgender patients, the Endocrine Society did not recommend prescribing medication like puberty blockers or hormones before patients reach puberty. The guidelines state that providers should create a multidisciplinary team — including mental health professionals — to treat adolescents with gender dysphoria, and counsel patients about fertility preservation before they begin puberty blockers or hormone therapy.

In a statement provided to Healio, the Endocrine Society pointed out that the use of puberty blockers and hormone therapy remains rare for adolescents, which “reflects a cautious approach as recommended in our guideline.”

As Healio previously reported, a study of private insurance claims from 2018 through 2022 found that fewer than 8,000 youth were prescribed puberty blockers and roughly 16,000 received hormone therapy over the 5-year period. No children aged younger than 12 years received hormone therapy.

A similar study on gender-affirming surgeries in the U.S. found that 85 adolescents received gender-affirming surgery in 1 year — almost all of which were breast reductions performed on cisgender boys.

In a joint statement, WPATH and the U.S. Professional Association for Transgender Health said the HHS report misrepresents existing research and WPATH’s methods for developing clinical practice guidelines.

WPATH published its first clinical practice guidelines in 1979. The most recent version, Standards of Care — Version 8, was published in 2022.

“Transgender young people deserve health care that is informed by science, compassion and respect,” the statement said. “Gender-affirming care is backed by rigorous research, expert consensus and patient-centered values. Studies consistently show its positive impact, including improved mental health and overall quality of life.”

AAP President Susan Kressly, MD, FAAP, said in a statement that the report fails to reflect the realities of pediatric care.

The AAP published a policy statement in 2018 and reaffirmed in 2023 that transgender youth should have access to safe, developmentally appropriate, gender-affirming health care and that pediatricians should advocate for policies that protect transgender youth.

“As we have seen with immunizations, bypassing medical expertise and scientific evidence has real consequences for the health of America’s children,” Kressly said in the statement. “AAP was not consulted in the development of this report, yet our policy and intentions behind our recommendations were cited throughout in inaccurate and misleading ways. The report prioritizes opinions over dispassionate reviews of evidence.”

Corman said the report should not impact patient care, which the authors noted themselves.

“However, it could trigger overcompliance or be used in lawsuits, even though it is not based in science,” Corman said.

Benefits of transition care

Madill stressed the benefits of gender-affirming care for youth, such as having “a body that fits your sense of who you are.”

“What we see is that kids who often do really well as little kids with just social transition — because when you’re a little kid, a name, a haircut and clothes are often sufficient for gender — all of a sudden go into a spiral of depression and anxiety when they hit adolescence because their body starts developing in ways that don’t fit who they know themselves to be,” she said. “It can be really psychologically traumatic. … Those things just feel really wrong. And we often see a lot of suicidality.”

Suicide prevention is one of the top reasons advocates champion gender-affirming care in youth and adolescents. Research has shown that transgender people face a higher risk for suicide than people who are not transgender and that suicide attempts rose when state-level anti-transgender laws were passed. Madill said the authors largely ignored suicidality in the report.

“There certainly is evidence that providing transition care to adults decreases suicidality dramatically,” she said. “The inference in this paper was it didn’t make a difference in children’s suicides to provide transition care, but I find that difficult to believe, particularly for teenagers, and that was where they were arguing in favor of just psychological care.”

But psychological care should be coupled with transition care, Madill explained.

“These are big decisions, and they should be made with the same care that other sorts of major health care decisions would be made. It should be made with the best interests of the child in mind,” she said. “Medical and psychological care should be provided to the child, not one or the other.”

References:

• AAP. Statement on HHS report treatment for pediatric gender dysphoria. https://www.aap.org/en/news-room/news-releases/aap/2025/aap-statement-on-hhs-report-treatment-for-pediatric-gender-dysphoria/. Published May 1, 2025. Accessed May 8, 2025.
• Coleman E, et al. Int J Transgender Health. 2022;doi:10.1080/26895269.2022.2100644.
• Dai D, et al. JAMA Netw Open. 2024;doi:10.1001/jamanetworkopen.2024.18814.
• Endocrine Society. A statement on medical care for transgender and gender-diverse youth. Provided May 8, 2025.
• Hembree WC, et al. J Clin Endocrin Metabol. 2017;doi:10.1210/jc.2017-01658.
• Hughes LD, et al. JAMA Pediatr. 2025;doi:10.1001/jamapediatrics.2024.6081.
• Human Rights Campaign. Map: Attacks on gender affirming care by state. https://www.hrc.org/resources/attacks-on-gender-affirming-care-by-state-map. Updated Dec. 4, 2024. Accessed May 7, 2025.
• KFF. Policy tracker: Youth access to gender affirming care and state policy restrictions. https://www.kff.org/other/dashboard/gender-affirming-care-policy-tracker/. Updated March 19, 2025. Accessed May 8, 2025.
• Rafferty J, et al. Pediatrics. 2018;doi:10.1542/peds.2018-2162.
• U.S. Department of Health and Human Services. HHS release comprehensive review of medical interventions for children and adolescents with gender dysphoria. https://www.hhs.gov/press-room/gender-dysphoria-report-release.html. Published May 1, 2025. Accessed May 8, 2025.
• U.S. Department of Health and Human Services. Treatment for pediatric gender dysphoria. https://opa.hhs.gov/sites/default/files/2025-05/gender-dysphoria-report.pdf. Published May 1, 2025. Accessed May 8, 2025.
• Williams Institute. How many adults and youth identify as transgender in the United States? https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/. Published June 2022. Accessed May 8, 2025.
• World Professional Association for Transgender Health. SOC-8 history and purpose. https://wpath.org/publications/soc8/soc8-history/. Accessed May 8, 2025.
• World Professional Association for Transgender Health. WPATH and USPATH response to the HHS report on gender dysphoria. https://wpath.org/wp-content/uploads/2025/05/WPATH-USPATH-Response-to-HHS-Report-02May2025-3.pdf. Published May 2, 2025. Accessed May 8, 2025.

For more information:

Jae D. Corman, PhD, and Stéphanie J. Madill, PhD, can be reached at pediatrics@healio.com.