by Susan Nagel

Susan Nagel holds a master’s degree in public affairs and worked as a planner/contract manager for the children’s mental health unit of a metropolitan county. Her daughter has been trans-identified for eight years and briefly medicalized. Nagel wrote an earlier piece for 4thWaveNow in 2017.

Here, Nagel provides an overview of the weak evidence being utilized by medical organizations to justify “affirmative care” for gender dysphoric young people. Particularly (and, increasingly, ONLY) in the United States, gender clinicians rely on the questionable recommendations of the World Professional Organization for Transgender Health (WPATH), the American Academy of Pediatrics (AAP), and the Endocrine Society to justify drug and surgical interventions for increasingly younger children.

The article is supported by extensive endnote sources. Readers seeking a deeper investigation into the poor evidence base for “affirming” pediatric gender medicine are encouraged to delve into these sources.

Editor’s note: Since the drafting of this article, an important exposé of WPATH has been released by the Environmental Progress organization, entitled The WPATH Files. The exposé features posts from an internal WPATH discussion forum, as well as footage from an online panel discussion. We encourage interested 4thWaveNow readers to examine the full document (linked above). X (formerly Twitter) users may want to search the #WPATHFiles tag to see press and other pertinent coverage of the controversy ensuing from the release of the exposé.

As of this writing, 23 states have passed laws restricting pediatric “gender-affirming” care[1] which may include medical interventions such as puberty blockers,[2] cross-sex hormones, and surgeries.[3] News coverage of these laws frequently notes that these procedures are endorsed by medical associations such as the American Academy of Pediatrics (AAP), the World Professional Association for Transgender Health (WPATH) and the Endocrine Society. [4]  Given the backing of these trusted organizations, the media and the public may believe that these interventions are safe and effective, and that the proponents of such restrictive laws are motivated by hate for trans people. However, a closer look at the guidelines for gender care published by these medical associations reveals that their endorsements are not based on solid evidence and are cavalier about risks.

Two medical associations, WPATH and the Endocrine Society, acknowledge within their own guidelines the poor evidence base for their positions.

WPATH’s Standards of Care

WPATH’s 2022 Standards of Care for the Health of Transgender and Gender Diverse People (SOC) asserts there is a “… slowly growing body of evidence supporting the effectiveness of early medical intervention…” for gender-diverse youth. Yet WPATH concedes that “… the number of studies is still low, and there are few outcome studies that follow youth into adulthood.” In fact, the number of studies is so low that WPATH claims a systematic review regarding outcomes is impossible, so it provides a short narrative review instead. [5]

Using a narrative rather than a systematic review to develop treatment guidelines is a troubling choice. Evidence-based medicine is built upon systematic reviews.  A systematic review examines every study on a chosen intervention, evaluates the results of each study for multiple sources of bias, and reaches a conclusion about an intervention based on the totality and quality of the evidence.  A narrative review can pick and choose which studies to review and uncritically accept study authors’ conclusions. [6] [7]

Even with the low bar of a narrative review, WPATH’s summary of the available research does not inspire confidence. The studies reviewed had small sample sizes.[8] and [9] only one followed adolescent patients into early adulthood, with subjects averaging 20.7 years old at study’s end.[10]

WPATH calls this Dutch study “the most robust longitudinal evidence supporting the benefits of gender-affirming medical and surgical treatment in adolescence.”[11] Indeed, this study is considered the “foundation” of the current practice of pediatric gender medicine.[12] Among its flaws, the Dutch study had no control group[13] and employed different measures of gender dysphoria pre and post treatment, thus hampering a meaningful comparison.[14] Fifteen subjects were dropped from the study, including four who developed serious health problems during treatment, thus skewing the results.[15] One of these subjects died from necrotizing fasciitis after undergoing genital surgery. [16] As Oxford Professor Michael Biggs wrote in his damning analysis of the research, “A fatality rate exceeding 1% would surely halt any other experimental treatment on healthy teenagers.”[17] With the Dutch study as its best evidence supporting affirmative care, WPATH is on shaky ground.

To the careful reader, WPATH fosters additional skepticism by asserting that puberty blockers are “fully reversible”[18] while stating in other places that the effects of puberty blockers on bone-mass,[19] neurodevelopment,[20] sexual health, and future surgical outcomes[21] are either not “well established,” “in need of continued study,” or “unknowns.”[22] WPATH also says patients considering puberty blockers should be informed of potential loss of fertility.[23]

Do puberty blockers cause infertility? Why is fertility a concern for a fully reversible drug?

From WPATH’s Standards of Care 8th Edition, (page S118)

Here is the issue: WPATH recommends that children begin blockers in very early puberty [24] before gametes (i.e. sperm or ova) have matured.[25] If children discontinue puberty blockers and seek no further treatment, natural puberty should occur, thus the claim of reversibility.[26] But children seldom end treatment with puberty blockers.  Almost all (between 93% and 98%) go on to take cross-sex hormones (CSHs)  [27] [28] [29] which requires continuous suppression of their own endogenous hormones.[30] [31] [32] Under these conditions, the gametes will not mature, with a likely future consequence of sterility.[33] [34] [35]  As late as 2020, there were no studies verifying the impact of puberty blockers followed by CSHs on fertility.[36] WPATH, AAP and the Endocrine Society all confirm this protocol threatens fertility[37] yet they nevertheless endorse it.[38]

From WPATH’s Standards of Care 7th Edition, (page 51)

From the AAP’s Policy Statement, (Footnote c. of Table 2 on page 6)

From the Endocrine Society Guidelines, (page 3878)

In addition to the risk of infertility, CSHs increase the risk for blood clots. [39] [40] [41] Even if the risk for blood clots returns to normal if a person stops treatment with CSHs, the consequences of a single blood clot can certainly be irreversible. CSHs also cause permanent changes to the body including deepening of the voice, increased body and facial hair, clitoral growth, and thinning scalp hair for natal females[42] and breast growth for natal males.[43]

From the NHS’s Cass Review of gender identity services (page 38, section 3.31)

While it is not known for certain why most children continue onto CSHs after puberty blockers, England’s National Health Service (NHS) has questioned whether puberty blockers ‘lock” children into gender identities by stopping maturation processes.[44] [45] Given the near certainty that children will continue onto CSHs with their risks and permanent changes, calling puberty blockers fully reversible is misleading.

The Endocrine Society’s Clinical Practice Guideline

Unlike WPATH, the Endocrine Society did use systematic reviews to inform its 2017 clinical practice guidelines.[46] Consequently, the Endocrine Society is able to document that all but one of its recommendations regarding the treatment of adolescents are based on low or very low-quality evidence. [47]

The AAP’s Policy Statement

The AAP’s 2018 policy statement on pediatric gender care[48] has caused alarm among both outsiders and even some AAP members.

Surprised by its affirmation-only approach, Canadian psychologist and sexologist James Cantor fact-checked the studies cited in the AAP’s policy statement. [49]  He found the AAP statement failed to reference outcomes from 11 studies that followed gender-dysphoric (GD) children as they matured. Every one of these studies, “…found the same thing: Over puberty, the majority of GD children ceased to want to transition.”[50] An affirmation-only approach makes no sense when research shows most children grow out of their gender dysphoria. Cantor also found the AAP statement relied heavily on research regarding adult sexual orientation which does not apply to GD children.[51] Cantor concluded, “Not only did AAP fail to provide compelling evidence, …. AAP’s recommendations are despite the existing evidence.”[52]

From “Transgender And Gender Diverse Children and Adolescents: Fact-Checking of AAP Policy, (page 6)

There have been at least eleven recent lawsuits filed by detransitioners[53] [54] who claim to have been harmed by “affirmative” gender care. One of these plaintiffs,  Isabelle Ayala, named the AAP as a defendant in her 2023 lawsuit against the clinicians who treated her.  Ayala began testosterone treatments about a month after her first visit to a gender clinic at 14. Physicians repeatedly increased her testosterone dose over the next year despite worsening depression and a suicide attempt. Ayala later detransitioned and came to understand her discomfort with her body stemmed from mental health comorbidities and the trauma of a childhood sexual assault, something her caregivers did not explore. Ayala’s suit accuses the AAP of misrepresenting the evidentiary support for its treatment recommendations and describes the AAP policy statement as “rife with outright fraudulent representations.”[55]

Some AAP pediatricians have been attempting to bring change to the organization. Each of the past three years, members of the AAP have submitted resolutions asking the AAP’s annual leadership forum for a review of the evidence regarding pediatric transition.[56] According to Julia Mason, one of the pediatricians involved, a resolution failed in 2020 because no one in leadership would second it; it was voted down by leadership in 2021 despite members placing it among the top five resolutions of interest in online voting; and it was “effectively bur[ied]” in 2022, when “…the AAP enforced for the first time a rule that shut down member comments….“[57]

AAP Policy Statements expire after five years unless reaffirmed.[58] The AAP Board of Directors voted to reaffirm the 2018 policy statement on gender-affirming care in August 2023.  According to an AAP press release, AAP leadership is “…confident the principles presented in the original policy … remain in the best interest of children.” Due to their concerns about the bans on “affirmative” care passing in many states, the AAP Board also “…authorized development of an expanded set of guidance for pediatricians based on a systematic review of the evidence.” Although the announcement of a systematic review is excellent news, declaring confidence in the 2018 policy statement prior to conducting the review seems to place the cart before the horse.[59]

European countries change course based on systematic reviews

So here is where “affirmative” care stands in early 2024: The AAP has misrepresented the evidence, WPATH has claimed systematic review is impossible, and the Endocrine Society has deemed low quality evidence sufficient to recommend risky treatments for minors. Yet health authorities in Finland, Sweden, and England are rethinking the use of puberty blockers and cross-sex hormones based on systematic reviews.  Finland’s 2020 treatment recommendations warn that “…gender reassignment of minors is an experimental practice,” and recommend psychosocial support, therapy and treatment of comorbid psychiatric disorders as “the first-line intervention”.[60] Swedish health authorities say the risks of treatment likely outweigh possible benefits,[61]  and along with England’s NHS now recommend that puberty blockers and CSHs be given only in the context of research programs. [62] [63]

From Sweden’s National Board of Health and Welfare 2022 Care of children and Adolescents with Gender Dysphoria Summary of National Guidelines, (page 3)

Transition does not prevent suicide

Mainstream reporting on gender care has not accurately conveyed the evidence and has often reiterated the gender affirmative advocates’ trump card; i.e.: medical interventions for gender dysphoria prevent suicide.[64] The literature does not support this claim. The systematic reviews commissioned by the NHS looked at the evidence related to mental health and suicide and found that CSHs may improve mental health, functioning and suicidality, but the evidence was of very low certainty.  The NHS cautioned that, “Any potential benefits of gender-affirming hormones must be weighed against the largely unknown long-term safety profile of these treatments….”[65] The NHS determined puberty blockers have little impact on mental health.[66] . A systematic review published by the Endocrine Society could not find sufficient evidence to “…draw a conclusion about the effect of hormone therapy on death by suicide.”[67]  Finnish researchers published a large study in February[68] that is the first to compare suicide rates among gender dysphoric patients who accessed gender reassignment services and those who did not. The study was also designed to tease out the role psychiatric morbidities play in suicide rates.  The study included 2083 adolescents who entered gender identity clinics and 16,643 matched controls. The researchers found,

• Gender dysphoria does not seem predictive of suicide deaths.
• “…medical gender reassignment does not have an impact on suicide risk.”
• The, “[m]ain predictor of mortality in this population is psychiatric morbidity….” When researchers controlled for psychiatric treatment needs, subjects in the control group versus the gender dysphoric group did not have statistically significant different levels of death by suicide.

It is incredibly unethical to constantly plant the idea that young people will be suicidal if they cannot access transition services when the evidence does not support this claim.

Dr. Will Malone, one of the few endocrinologists to speak out[69] about the weak evidence base, summed up the state of pediatric gender medicine in an interview, ”… [W]e’re essentially running an experiment outside of experimental protocols, … [T]hat’s not how medicine is supposed to work. You’re supposed to do the experiments first, show that the treatment works, especially when you’re talking about infertility and sexual dysfunction long-term and … a four times increased risk of heart disease and a two to three times increased rate of development of blood clots and strokes….”[70]

The medical association endorsements of gender-affirming medical treatments for minors are not based on solid evidence. News sources should stop treating medical associations as oracles. They are institutions vulnerable to ideological capture, and the validity of their endorsements must be examined. Through their endorsements, medical associations are failing the patients, families, clinicians, lawmakers, judges, and reporters who rely on their advice.  Because of this carelessness, patient health has been compromised; vulnerable people too young to know their child-bearing wishes have been sterilized and/or left unable to breastfeed; patients have spent years and resources chasing unattainable goals, and families have been torn apart. Medical associations have betrayed the public’s trust and must return to the principles of evidence-based medicine to regain it. Gender-dysphoric youth have an equal right to care based on the evidence rather than ideology.

[1] Dawson, Lindsey and Jennifer Kates, “Policy tracker: Youth Access to Gender Affirming Care and State Policy Restrictions.” KFF, 31 January 2024. https://www.kff.org/other/dashboard/gender-affirming-care-policy-tracker/

[2] “Pubertal Blockers for Transgender and Gender-diverse Youth.” Mayo Clinic, 18 June 2022, www.mayoclinic.org/diseases-conditions/gender-dysphoria/in-depth/pubertal-blockers/art-20459075 Note: If you look at some of the works cited in this editorial, you will see references to gonadotropin-releasing hormone analogues (GnRH analogues or GnRHa) rather than to puberty blockers. The referenced Mayo Clinic site says, “The medications mostly commonly used to suppress puberty are known as gonadotropin-releasing hormone (GnRH) analogues.” I used the term, puberty blockers, in this piece because it is more descriptive than gonadotropin-releasing hormone analogues.

[3] Rafferty, Jason. “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents.” Pediatrics, vol. 142, no. 4, 2018, pp. 1-14, https://publications.aap.org/pediatrics/article/142/4/e20182162/37381/Ensuring-Comprehensive-Care-and-Support-for (page 6). Note: Table 2 on page 6 lists the interventions.

[4] Below are quotes from six major news organizations demonstrating how reporters use the endorsements of medical associations to support the idea that gender-affirming care is safe and/or best practice.

1. 1. 1. Olson, Jeremy. “‘It Got Very Bad, Very Quickly’: Families with Transgender Kids Seek Refuge in Minnesota.” Star Tribune, 6 May 2023. https://www.startribune.com/minnesota-transgender-refuge-children-families-move-gender-affirming-care/600272910/ Quote: “An estimated 40% of transgender children have attempted suicide, which is one reason the American Academy of Pediatrics and the American Medical Association endorse gender-affirming care.”
      2. Nawaz, Amna, and Matt Loffman. “Claiming Abuse, Texas Tries to Prevent Gender-affirming Care for Trans Children.” PBS News Hour, 24 Feb. 2022. https://www.pbs.org/newshour/show/claiming-abuse-texas-tries-to-prevent-gender-affirming-care-for-trans-children Quote: “Medical experts, including the American Academy of Pediatrics, say gender-affirming care is safe and best practice for transgender patients.”
      3. Ceron, Eron, and Kelsey Butler. “State lawmakers are pushing anti-trans legislation at record rates.” Wisconsin State Journal, 5 Apr. 2023. https://madison.com/news/national/state-lawmakers-are-pushing-anti-trans-legislation-at-record-rates/article_d8ac2a3f-bf67-5c4a-8be0-b868178fe54d.html Quote: “The American Academy of Pediatrics, the American Psychological Association, the World Professional Association for Transgender Health and other leading medical groups all recognize gender-affirming care as the standard of care for transgender youth.”
      4. Rayasam, Renuka. “The Transgender Care That States Are Banning, Explained.” Politico, 25 March 2022. https://www.politico.com/newsletters/politico-nightly/2022/03/25/the-transgender-care-that-states-are-banning-explained-00020580 Quote: “The American Academy of Pediatrics, the World Professional Association for Transgender Health and other medical associations have published detailed guidelines…” on the practice of gender-affirming care.
      5. Christensen, Jen. “Gender-affirming care, a ‘crucial’ process for thousands of young people in America.” CNN health. 25 April 2023. https://www.cnn.com/2022/04/21/health/gender-affirming-care/index.html Quote: “Major medical associations – including the American Medical Association, the American Psychiatric Association, the American Academy of Pediatrics and the American Academy of Child & Adolescent Psychiatry – agree that gender-affirming care is clinically appropriate for children and adults. The World Professional Association for Transgender Health’s guidelines, which are considered the gold standard and guide gender-affirming care around the world, say it should be a way for people to create ‘effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being and self-fulfillment.’”
      6. Fawcett, Eliza. “After Arkansas Trial, Judge Weighs Legality of Ban on Care for Transgender Youth.” The New York Times, 4 Dec. 2022. https://www.nytimes.com/2022/12/04/us/arkansas-hormone-therapy-transgender.html Quote: “Leading medical associations, including the Endocrine Society and the American Academy of Pediatrics recommend access to such care for transgender people under 18….”

[5] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258,  Standards of Care – WPATH World Professional Association for Transgender Health (Page S46). Quote: “Despite the slowly growing body of evidence supporting the effectiveness of early medical intervention, the number of studies is still low, and there are few outcome studies that follow youth into adulthood. Therefore, a systematic review regarding outcomes of treatment in adolescents is not possible. A short narrative review is provided instead.”

[6]  Patole, Sanjay. “Systematic Reviews, Meta-Analysis, and Evidence-Based Medicine.”  Principles and Practice of Systematic Reviews and Meta-Analysis, by Patole, Sanjay (ed.), Springer, Cham, 2021, pp. 1-10. https://doi.org/10.1007/978-3-030-71921-0_1

[7] Abbruzzese, Zhenya. “Episode 118: Prioritizing Expensive & Invasive Interventions: American Healthcare w/Zhenya Abbruzzese.” Interview by Sasha Ayad and Stella O’Malley for the Gender A Wider Lens Podcast, YouTube, 16 June 2023  https://www.youtube.com/watch?v=YhLA02Dtupc&t=170s  (minutes 52:29 to 59:07).

[8] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health (page S47). Quote: “To conclude, although the existing samples reported on relatively small groups of youth (e.g., n = 22-101 per study) and the time to follow-up varied across studies (6 months-7 years), this emerging evidence base indicates a general improvement in the lives of transgender adolescents who … receive medically necessary gender-affirming medical treatment.”

[9] de Vries, A. L. C., et al. “Young Adult Psychological Outcome after Puberty Suppression and Gender Reassignment.” PEDIATRICS, vol. 134, no. 4, 8 Sept. 2014, pp. 696–704, Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment | Pediatrics | American Academy of Pediatrics (aap.org)  Note: This is the citation for the Dutch study WPATH is discussing. WPATH and journal articles reference it as de Vries et al., 2014 or de Vries et al. (2014)

[10] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S46). Quote: “The 2014 long-term follow-up study is the only study that followed youth from early adolescence (pretreatment, mean age of 13.6) through young adulthood (posttreatment, mean age of 20.7).”

[11] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S51). Quote: “The most robust longitudinal evidence supporting the benefits of gender-affirming medical and surgical treatments in adolescence was obtained in a clinical setting that incorporated a detailed comprehensive diagnostic assessment process over time into its delivery of care protocol (de Vries & Cohen-Kettenis, 2012; de Vries et al., 2014).” Note: WPATH refers to both de Vries & Cohen-Kettenis, 2012 and de Vries et al., 2014 as the most robust longitudinal evidence supporting gender affirmative medical treatments.  De Vries et al., 2014 is the study I critique in this paragraph of my editorial. De Vries & Cohen-Kettenis, 2012 is not a study but a description of the protocol used in de Vries et al., 2014.

[12] Dutch researchers pioneered the treatment regimen of puberty blockers followed by cross sex hormones and surgery(ies), so the regimen has become known as the Dutch Protocol.  The Dutch study referenced by WPATH, i.e. de Vries et al., 2014, is used to justify this now widespread protocol, so that is why I discuss it in such detail.  Sources for the information in this endnote are below.

1. 1. 1. Biggs, Michael. “The Dutch Protocol for Juvenile Transsexuals: Origins and Evidence.” Journal of Sex & Marital Therapy, 19 Sept. 2022, pp. 1–21, https://www.tandfonline.com/doi/full/10.1080/0092623X.2022.2121238 ‌(page 1). Quote: “The use of Gonadotropin-Releasing Hormone agonist (GnRHa) drugs to suppress puberty in ’juvenile transsexuals’ was first proposed in print in the mid-1990s (Gooren & Delemarre-van de Waal, 1996). Developed by three clinicians at Utrecht and Amsterdam, this intervention became known as the Dutch protocol.”
      2. Abbruzzese, E., et al. “The Myth of ‘Reliable Research’ in Pediatric Gender Medicine: A Critical Evaluation of the Dutch Studies -and Research That Has Followed.” Journal of Sex & Marital Therapy, 2023, pp. 1-27, Full article: The Myth of “Reliable Research” in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies—and research that has followed (tandfonline.com) (page 2). This journal article describes how the de Vries et al., 2014 study helped spread the Dutch Protocol. Quote: “To demonstrate problems in the existing research, we discussed two seminal studies that gave rise to the now-common practice of performing gender transitions on young people by giving them puberty blockers, cross-sex hormones, and ‘gender-affirming’ surgery (de Vries et al., 2011; de Vries et al., 2014).” (page 4) Quote: “There is no argument that the Dutch experience, and in particular two Dutch studies—de Vries et al. (2011), and de Vries et al. (2014)—forms the foundation of the practice of youth gender transition.”

[13] Abbruzzese, E., et al. “The Myth of ‘Reliable Research’ in Pediatric Gender Medicine: A Critical Evaluation of the Dutch Studies -and Research That Has Followed.” Journal of Sex & Marital Therapy, 2023, pp. 1-27, Full article: The Myth of “Reliable Research” in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies—and research that has followed (tandfonline.com) (page 5). Quote: “Besides the lack of a control group and a small final sample of 55 cases with key outcomes available for as few as 32 individuals, there are three major areas of concern that render these studies unfit for clinical or policy decision making.”

[14] Abbruzzese, E., et al. “The Myth of ‘Reliable Research’ in Pediatric Gender Medicine: A Critical Evaluation of the Dutch Studies -and Research That Has Followed.” Journal of Sex & Marital Therapy, 2023, pp. 1-27,  Full article: The Myth of “Reliable Research” in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies—and research that has followed (tandfonline.com) (pages 7-10). Note: The Dutch study used the Utrecht Gender Dysphoria Scale (UGDS) to measure levels of gender dysphoria in their subjects. The UGDS has different scales for males and females. For a male subject, the researchers used the male version of the scale before transition and switched to the female version after transition and vice versa for female subjects. This means the researchers are asking males questions about how they feel about being men before transition and questions about how they feel about being women after transition. To measure a change, researchers should have developed an instrument that could be used both pre and post treatment. In the link at the end of this note, two gender therapists familiar with the Dutch study point out that subjects probably would have answered the post-treatment scale the same way without any intervention. That is, a male who wants to transition would react positively to statements about being a woman before doing any medical treatments, so the answers indicate nothing about the effectiveness of the treatment.  The answers only indicate the subject’s desire which has not changed. https://www.youtube.com/watch?v=UnmAQGVdpr8&list=PLngVCeAoK6vudCwfy0R2Rvg_SH2QxBJTu&index=2

[15] Abbruzzese, E., et al. “The Myth of ‘Reliable Research’ in Pediatric Gender Medicine: A Critical Evaluation of the Dutch Studies -and Research That Has Followed.” Journal of Sex & Marital Therapy, 2023, pp. 1-27, Full article: The Myth of “Reliable Research” in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies—and research that has followed (tandfonline.com) (page 7). Quote: “Fifteen subjects were dropped from the study and relabeled ‘nonparticipants.’ This subset, however, was not random, but instead heavily skewed toward subjects who experienced serious problems, including 3 who developed severe diabetes and obesity and 1 death following surgical complications.”

[16] de Vries, A. L. C., et al. “Young Adult Psychological Outcome after Puberty Suppression and Gender Reassignment.” PEDIATRICS, vol. 134, no. 4, 8 Sept. 2014, pp. 696–704, Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment | Pediatrics | American Academy of Pediatrics (aap.org) (page 697). Note: This citation is to the referenced Dutch study. Quote:‌ “Nonparticipation…, 1 trans female died after her vaginoplasty owing to a postsurgical necrotizing fasciitis.”

[17] Biggs, Michael. “The Dutch Protocol for Juvenile Transsexuals: Origins and Evidence.” Journal of Sex & Marital Therapy, 19 Sept. 2022, pp. 1–21, https://www.tandfonline.com/doi/full/10.1080/0092623X.2022.2121238 (page 8). Note: Biggs states that the use of puberty blockers contributed to the patient’s death. Quote: “The authors did not mention the fact that this death was a consequence of puberty suppression: the patient’s penis, prevented from developing normally, was too small for the regular vaginoplasty and so surgery was attempted with a portion of the intestine, which became infected (Negenborn et al., 2017). A fatality rate exceeding 1% would surely halt any other experimental treatment on healthy teenagers.”

[18] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S112). Quote: “Since this treatment is fully reversible, it is regarded as an extended time for adolescents to explore their gender identity by means of an early social transition.”

[19] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health (page S114). Quote: “…the long-term effects on bone mass have not been well established.” and (page S65) Quote: “…there are concerns delaying exposure to sex hormones (endogenous or exogenous) at a time of peak bone mineralization may lead to decreased bone mineral density. The potential decrease in bone mineral density as well as the clinical significance of any decrease requires continued study.”

[20] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S65). Quote: “The potential neurodevelopmental impact of extended pubertal suppression in gender diverse youth has been specifically identified as an area in need of continued study.”

[21]Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S64). Quote: “This underscores the importance of engaging in discussions with families about the future unknowns related to surgical and sexual health outcomes.”

[22] See the quotes in footnotes 19 through 21 for the references to “not been well established,” “in need of continued study” and “unknowns.”

[23] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S256 under the section on Puberty blocking agents). Note: On this page, WPATH lists one of the criteria for receiving puberty blockers as informing the patient of the “…reproductive effects, including the potential loss of fertility….”

[24] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S112). Note: WPATH provides the following guidance for determining when to start puberty blockers, “When a child reaches an age where pubertal development would normally begin (typically from 7-8 to 13 years for those with ovaries and from 9 to 14 years for those with testes), it would be appropriate to screen the child more frequently, perhaps at 4-month intervals, for signs of pubertal development (breast budding or testicular volume > 4 cc).”

[25] Finlayson, Courtney, et al. “Proceedings of the Working Group Session on Fertility Preservation for Individuals with Gender and Sex Diversity.” Transgender Health, vol. 1, no. 1, 2016, pp. 99–107, https://www.liebertpub.com/doi/10.1089/trgh.2016.0008 (page 100). Quote: “Pubertal suppression treatment, prescribed to youth with gender dysphoria as early as Tanner state 2 of puberty, pauses the development of undesired puberty, including some irreversible secondary sexual characteristics, but also prevents maturation of primary oocytes and spermatogonia to mature oocytes and sperm.”

[26] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S157). Quote: “GnRHas impact the maturation of gametes but do not cause permanent damage to gonadal function. Thus, if GnRHas are discontinued, oocyte maturation would be expected to resume.” and (page S158) “GnRHas inhibit spermatogenesis. Data suggest discontinuation of treatment results in a re-initiation of spermatogenesis, although this may take at least 3 months and most likely longer.”

[27] “The Cass Review Independent Review of Gender Identity Services for Children and Young People: Interim Report.” NHS England and NHS Improvement, Feb. 2022, The Cass Review – Independent review of gender identity services for children and young people: Interim Report  (page 38. section 3.31). Quote: “The most difficult question is whether puberty blockers do indeed provide valuable time for children and young people to consider their options, or whether they effectively ‘lock in’ children and young people to a treatment pathway which culminate in progression to feminising/masculinising hormones by impeding the usual process of sexual orientation and gender identity development. Data from both the Netherlands and the study conducted by GIDS demonstrated that almost all children and young people who are put on puberty blockers go on to sex hormone treatment (96.5% and 98% respectively).”

[28] Biggs, Michael. “The Dutch Protocol for Juvenile Transsexuals: Origins and Evidence.” Journal of Sex & Marital Therapy, 19 Sept. 2022, pp. 1–21, ‌https://www.tandfonline.com/doi/full/10.1080/0092623X.2022.2121238 (page 5). Quote: “Subsequent experience in the Netherlands and other countries confirms the fact that 96%-98% of children who undergo puberty suppression continue to cross-sex hormones.”

[29] Van der Loos, Maria ATC, et al. “Children and adolescents in the Amsterdam Cohort of Gender Dysphoria: trends in diagnostic and treatment trajectories during the first 20 years of the Dutch Protocol.” The Journal of Sexual Medicine, vol. 20, Issue 3, March 2023, pp. 398-409, https://academic.oup.com/jsm/article/20/3/398/7005631?login=false  (page 407). Note: In this document, the Dutch researchers themselves acknowledge that most children who take puberty blockers continue to cross sex hormones. Quote: “The majority of adolescents (93%) using GnRHa go on to start with GAH [gender-affirming hormones]. This finding may imply that GnRHa treatment is used as a start of transition rather than an extension of the diagnostic phase.”

[30] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S115, Statement 12.6). Quote: “We recommend health care professionals measure hormone levels during gender-affirming treatment to ensure endogenous sex steroids are lowered and administered sex steroids are maintained at a level appropriate for the treatment goals for transgender and gender diverse people….”

[31] Hembree, Wylie C, et al. “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline.” The Journal of Clinical Endocrinology & Metabolism, vol. 102, no. 11, 13 Sept. 2017, pp. 3869–3903, https://academic.oup.com/jcem/article/102/11/3869/4157558  (pages 3885-3886). The Endocrine Society Guidelines state that one of the major goals of cross sex hormone therapy is “…to reduce endogenous sex hormone levels, and thus reduce the secondary sex characteristics of the individual’s designated gender….”

[32] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S115). Note: This page in the SOC explains that in addition to taking estrogen to develop female secondary sex characteristics, natal males must also take medication to block endogenous testosterone production to prevent development of male secondary sex characteristics. Testosterone both blocks the production of endogenous estrogen and develops male secondary sex characteristics, so natal females do not need a second medication to block estrogen production.

[33] Mayhew, Allison C, and Veronica Gomez-Lobo. “Fertility Options for the Transgender and Gender Nonbinary Patient.” The Journal of Clinical Endocrinology & Metabolism, vol. 105, no. 10, 14 Aug. 2020, pp. 3335–3345,‌ https://academic.oup.com/jcem/article/105/10/3335/5892794?login=false (page 3337). Quote: “… significant concerns have been raised regarding the viability of fertility options for gonads that have not undergone puberty.”

[34] Joyce, Helen. Trans: When Ideology Meets Reality, Oneworld Publications, London, 2021 (page 91). Quote: “But there is no doubt about an indirect harm that will be suffered by any children who start taking them [puberty blockers] young enough to avoid puberty altogether: sterility. Cross-sex hormones cause the secondary sex characteristics of the desired sex to develop – breasts, beards, and so on – but only a person’s own sex’s hormones can cause their ovaries or testicles to mature.”

[35]  “Pubertal Blockers.” UCLA Gender Health Program,  https://www.uclahealth.org/sites/default/files/documents/Pubertal_Blocker_Patient_Information.pdf   Note: This is an information sheet on puberty blockers from the UCLA (University of California Los Angeles) Gender Health Program. Quote: “If the pubertal blockers are started in early puberty, you may never be able to make fertile sperm or eggs, especially if you decide to continue on to hormone therapy later.”

[36] Mayhew, Allison C, and Veronica Gomez-Lobo. “Fertility Options for the Transgender and Gender Nonbinary Patient.” The Journal of Clinical Endocrinology & Metabolism, vol. 105, no. 10, 14 Aug. 2020, pp. 3335–3345,‌ https://academic.oup.com/jcem/article/105/10/3335/5892794?login=false (page 3337). Note: I say, as late as 2020, because this 2020 journal article states, “To date, there are no studies addressing fertility potential of gonads treated with pubertal suppression and subsequent gender-affirming hormone therapy, but significant concerns have been raised regarding the viability of fertility options for gonads that have not undergone puberty.”

[37]This endnote contains quotes from the AAP Policy Statement, the Endocrine Society Guidelines, the WPATH SOC 7^th edition, and the WPATH SOC 8^th edition demonstrating that the medical associations know treatment with puberty blockers in early puberty followed by cross sex hormones threatens fertility.

1. 1. 1. 1. 1. Rafferty, Jason. “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents.” Pediatrics, vol. 142, no. 4, 2018, pp. 1-14, https://publications.aap.org/pediatrics/article/142/4/e20182162/37381/Ensuring-Comprehensive-Care-and-Support-for (p. 6, Footnote c. of Table 2). This quote is buried in a footnote under a table. Quote: “The effect of sustained puberty suppression on fertility is unknown. Pubertal suppression can be, and often is indicated to be followed by cross-sex hormone treatment.  However, when cross-sex hormones are initiated without endogenous hormones, then fertility may be decreased.”
            2. Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health (page S118). “Pubertal suppression and hormone treatment with sex steroid hormones may have potential adverse effects on a person’s future fertility.”
            3. Coleman, Eli, et al. “Standards of Care for the Health of Transsexual, Transgender, and Gender NonConforming People, 7th Version.” World Professional Association for Transgender Health, 2012, pp. 1-112, https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_English.pdf (page 51). Note: The seventh edition of WPATH’s SOC was more explicit about the impact of starting drug treatments on people with immature reproductive systems.  Quote: “A special group of individuals are prepubertal or pubertal adolescents who will never develop reproductive function in their natal sex due to blockers or cross-gender hormones.”
            4. Hembree, Wylie C, et al. “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline.” The Journal of Clinical Endocrinology & Metabolism, vol. 102, no. 11, 13 Sept. 2017, pp. 3869–3903, https://academic.oup.com/jcem/article/102/11/3869/4157558 (page 3878). Note: The Endocrine Society Guidelines say that to be eligible for puberty blockers, adolescents must be “…informed of the effects and side effects of treatment (including potential loss of fertility if the individual subsequently continues with sex hormone treatment)….”

[38] In the following quotes, the AAP, WPATH and the Endocrine Society endorse the protocol of puberty blockers followed by cross sex hormones as a standard treatment for gender dysphoria.

1. 1. 1. 1. 1. Rafferty, Jason. “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents.” Pediatrics, vol. 142, no. 4, 2018, pp. 1-14, https://publications.aap.org/pediatrics/article/142/4/e20182162/37381/Ensuring-Comprehensive-Care-and-Support-for (p. 6). Quote: “Most protocols for gender-affirming interventions incorporate World Professional Association of Transgender Health and Endocrine Society recommendations and include [ 1 or more] of the following elements….” The elements listed include social affirmation, puberty blockers, cross-sex hormone therapy, gender-affirming surgeries, and legal affirmation.
            2. Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health (page S115). Quote: “When GnRHa treatment is started in the early stages of endogenous pubertal development, puberty corresponding with gender identity or embodiment goals is induced with doses of sex steroid hormones similar to those used in peripubertal hypogonadal adolescents. In this context, adult doses of sex steroid hormones are typically reached over approximately a 2-year period (Chantrapanichkul et al., 2021).”
            3. Hembree, Wylie C, et al. “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline.” The Journal of Clinical Endocrinology & Metabolism, vol. 102, no. 11, 13 Sept. 2017, pp. 3869–3903, https://academic.oup.com/jcem/article/102/11/3869/4157558 (page 3871, sections 2.1 and 2.4). Quote: “2.1 We suggest that adolescents who meet diagnostic criteria for GD/gender incongruence, fulfill criteria for treatment, and are requesting treatment should initially undergo treatment to suppress pubertal development.” and “2.4 In adolescents who request sex hormone treatment (given this is a partly irreversible treatment), we recommend initiating treatment using a gradually increasing dose schedule after a multidisciplinary team of medical and MHPs has confirmed the persistence of GD/gender incongruence and sufficient mental capacity to give informed consent, which most adolescents have by age 16 years.”

[39] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S254, Table 2). Note: Table 2 lists the clinically significant risks associated with cross sex hormones as venous thromboembolism in natal males, polycythemia in natal females, and infertility in both. The reference cited in endnote 49 defines venous thromboembolism as blood clots that block blood flow. The reference cited in endnote 41 defines polycythemia as an increase in red blood cells that increases the risk of blood clots. Rather than get into a discussion of venous thromboembolism and polycythemia in this editorial, I simplify by saying cross sex hormones increase the risk of blood clots. There are other risks associated with cross sex hormones, but to be conservative, I limited my discussion to those WPATH says are clinically significant. I do not know if the risk for venous thromboembolism or polycythemia reverses if a person stops treatment with CSHs, however, the consequences of a blood clot may certainly be irreversible.

[40] “Venous Thromboembolism.” Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/22614-venous-thromboembolism

[41] Johnson, Jon. “Polycythemia: Everything you need to know.” Medical News Today, 31 March 2023, https://www.medicalnewstoday.com/articles/polycythemia

[42] “Masculinizing hormone therapy.” Mayo Clinic, 21, February 2023 https://www.mayoclinic.org/tests-procedures/masculinizing-hormone-therapy/about/pac-20385099 Quote: “Some of the physical changes caused by masculinizing hormone therapy can be reversed if you stop taking testosterone. Others, such as a deeper voice, a larger clitoris, scalp hair loss, and increased body and facial hair, cannot be reversed.”

[43] “Feminizing hormone therapy.” Mayo Clinic, 21, February 2023 https://www.mayoclinic.org/tests-procedures/feminizing-hormone-therapy/about/pac-20385096 Quote: “Some of the physical changes caused by feminizing hormone therapy can be reversed if you stop taking it. Others, such as breast development, cannot be reversed.”

[44] “The Cass Review Independent Review of Gender Identity Services for Children and Young People: Interim Report.” NHS England and NHS Improvement, Feb. 2022, The Cass Review – Independent review of gender identity services for children and young people: Interim Report (page 38. section 3.31). Quote: “The most difficult question is whether puberty blockers do indeed provide valuable time for children and young people to consider their options, or whether they effectively ‘lock in’ children and young people to a treatment pathway which culminate in progression to feminising/masculinising hormones by impeding the usual process of sexual orientation and gender identity development.”

[45] Biggs, Michael. “The Dutch Protocol for Juvenile Transsexuals: Origins and Evidence.” Journal of Sex & Marital Therapy, 19 Sept. 2022, pp. 1–21, https://www.tandfonline.com/doi/full/10.1080/0092623X.2022.2121238 ‌(page 5). Note: Biggs has also questioned whether puberty blockers cement trans identities rather than giving patients more time to explore their identities.  Quote: “GnRHa was posited to provide space for therapeutic exploration of gender identity, without the pressure of the physical changes accompanying puberty (Delemarre-van de Waal & Cohen-Kettenis, 2006). This claim was plausible, though it was also plausible that stopping normal cognitive, emotional, and sexual development would impede such exploration.”

[46] Hembree, Wylie C, et al. “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline.” The Journal of Clinical Endocrinology & Metabolism, vol. 102, no. 11, 13 Sept. 2017, pp. 3869–3903, https://academic.oup.com/jcem/article/102/11/3869/4157558  (Paragraph titled, Evidence, on page 3869). Quote: “This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies.”

[47] Hembree, Wylie C, et al. “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline.” The Journal of Clinical Endocrinology & Metabolism, vol. 102, no. 11, 13 Sept. 2017, pp. 3869–3903, https://academic.oup.com/jcem/article/102/11/3869/4157558 (pages 3871-3872). A description of the evidence grading system is found on page 3872 in the section titled, Method of Development of Evidence-Based Clinical Practice Guidelines. Recommendations and suggestions for treating adolescents may be found on page 3871: sections 1.4, 1.5 and sections 2.1 through 2.6; and page 3872: sections 5.5 & 5.6. At the end of each recommendation or suggestion, the supporting evidence is graded.  The supporting evidence for seven recommendations has a grade of “low quality,” and the supporting evidence for three recommendations has a grade of “very low quality.” The evidence for one recommendation to give adolescents information on options for fertility preservation has a grade of “moderate quality.”

[48] Rafferty, Jason. “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents.” Pediatrics, vol. 142, no. 4, 2018, pp. 1-14, https://publications.aap.org/pediatrics/article/142/4/e20182162/37381/Ensuring-Comprehensive-Care-and-Support-for

[49] Cantor, James M. “Transgender and Gender Diverse Children and Adolescents: Fact-Checking of AAP Policy.” Journal of Sex & Marital Therapy, 2019, pp. 1-7, https://www.ohchr.org/sites/default/files/Documents/Issues/SexualOrientation/IESOGI/Other/Rebekah_Murphy_20191214_JamesCantor-fact-checking_AAP-Policy.pdf (page 1). Quote: “Although almost all clinics and professional associations in the world use what’s called the watchful waiting approach to helping transgender and gender diverse (GD) children, the AAP statement rejected that consensus, endorsing only gender affirmation…. With AAP taking such a dramatic departure from other professional associations, I was immediately curious about what evidence led them to that conclusion.”

[50] Cantor, James M. “Transgender And Gender Diverse Children and Adolescents: Fact-Checking of AAP Policy.” Journal of Sex & Marital Therapy, 2019, pp. 1-7,  https://www.ohchr.org/sites/default/files/Documents/Issues/SexualOrientation/IESOGI/Other/Rebekah_Murphy_20191214_JamesCantor-fact-checking_AAP-Policy.pdf (page 1).

[51] Cantor, James M. “Transgender And Gender Diverse Children and Adolescents: Fact-Checking of AAP Policy.” Journal of Sex & Marital Therapy, 2019, pp. 1-7, https://www.ohchr.org/sites/default/files/Documents/Issues/SexualOrientation/IESOGI/Other/Rebekah_Murphy_20191214_JamesCantor-fact-checking_AAP-Policy.pdf (pages 2-3). Note: Cantor discusses how the AAP inappropriately cites research regarding conversion therapy for adult homosexuals in its recommendations for treating GD children. Quote: “That is, in the context of GD children, it simply makes no sense to refer to externally induced ‘conversion’: The majority of children ‘convert’ to cisgender or ‘desist’ from transgender regardless of any attempt to change them. ‘Conversion’ only makes sense with regard to adult sexual orientation because (unlike childhood gender identity), adult homosexuality never or nearly never spontaneously changes to heterosexuality. Although gender identity and sexual orientation may often be analogous and discussed together with regard to social or political values and to civil rights, they are nonetheless distinct-with distinct origins, needs, and responses to medical and mental health care choices.”

[52] Cantor, James M. “Transgender And Gender Diverse Children and Adolescents: Fact-Checking of AAP Policy.” Journal of Sex & Marital Therapy, 2019, pp. 1-7, https://www.ohchr.org/sites/default/files/Documents/Issues/SexualOrientation/IESOGI/Other/Rebekah_Murphy_20191214_JamesCantor-fact-checking_AAP-Policy.pdf (page 6).

[53] The list of lawsuits appears below:

1. 1. 1. Plaintiff’s Petition. State of Rhode Island Superior Court. Isabelle M. Ayala American Academy of Pediatrics, et al. Case Number: PC 2023-0542B. Submitted 23 October 2023. https://dw-wp-production.imgix.net/2023/10/Ayala-v-AAP-Complaint_stamped.pdf
      2. Plaintiff’s Original Petition. District Court of Tarrant County, Texas. Soren Aldaco v. Del Scott Perry, et al. https://first-heritage-foundation.s3.amazonaws.com/live_files/2023/07/Aldaco-Plaintiffs-Original-Petition-Final.pdf
      3. First Amended Complaint. Circuit Court of The State of Oregon for the County of Multnomah. Camille Kiefel v. Amy Ruff, et al. Case No.: 22CV29327. Submitted 12 December 2022. https://static1.squarespace.com/static/5f232ea74d8342386a7ebc52/t/63a0afdfc02f9322762974cf/1671475168006/Kiefel+First+Amended+Complaint+%28file+stamped%29.pdf
      4. Plaintiff’s Complaint. Superior Court of the State of California in and for the County of San Joaquin – Stockton Branch. Kayla Lovdahl v. Kaiser Foundation Hospitals, Inc., et al. https://s3.documentcloud.org/documents/23848578/layla-jane-lawsuit.pdf
      5. Plaintiff’s Complaint. Superior Court of the State of California in and for the County of San Joaquin – Stockton Branch. Chloe E. Brockman a.k.a. Chloe Cole v. Kaiser Foundation Hospitals, Inc., et al. Filed 22 February 2023. https://s3.documentcloud.org/documents/23693707/chloe-complaint-clean.pdf
      6. Plaintiff’s Complaint. District Court of Douglas County, Nebraska. Luka Hein UNMC Physicians, et al. Case Number: D01CI230007381. Submitted 13 September 2023. https://www.nationalreview.com/wp-content/uploads/2023/09/FILE_3605.pdf
      7. Plaintiff’s Complaint and Jury Demand. State of North Carolina County of Gaston in the General Court of Justice Superior Court Division 23 CVS 2375. Charlie Mosely a.k.a. Prisha Mosely a.k.a. Abigail Mosely v. Eric T. Emerson, et al. Filed 17 July 2023. https://s3.documentcloud.org/documents/23882834/prisha-mosley-complaint.pdf
      8. First Amended Complaint. Superior Court of the State of California for the County of San Francisco. Richard Ikechukwu Anumene a.k.a. Rika Ilay Abbir v. The Permanente Medical Group, Inc., et al. Case No.: CGC-22-598800. Filed 10 May 2022. https://detranshelp.org/wp-content/uploads/2023/07/Richard-Ikechukwu-Anumene-Frirst-Amended-Complaint-Filed.pdf
      9. Verified Complaint for Damages. United States District Court for the District of Massachusetts Eastern Division. July R. Carlan a.k.a. Shape Shifter v. Fenway Community Health Center, Inc. Case 1:23-cv-12361-RWZ. Filed 12 October 2023. https://mnf-law.com/wp-content/uploads/2023/11/ShapeShifter-v-Fenway.pdf
      10. Amended Complaint. Providence/Bristol County, Rhode Island Superior Court. Hannah Ulery v. Jason R. Rafferty, et al. Case Number: PC-2023-05366. Submitted 23 October 2023. https://legalinsurrection.com/wp-content/uploads/2023/11/Ulery-Amended-Complaint-filed.pdf
      11. Davidoff, Judith. “Firm suing UW doctors over transgender care seeks clients for similar lawsuits.” Isthmus, 5 January 2024. https://isthmus.com/news/news/firm-suing-uw-doctors-over-transgender-care-seek-clients-for/ Note: This is a story about a suit filed by a “Jane Doe” against the Injured Patients and Families Compensation Fund and the University of Wisconsin Hospitals and Clinics Authority. The plaintiff’s petition is not available.

[54] “Eleven Lawsuits by Detransitioners in the US.” BROADview, 7 December 2023. Newsletter https://www.broadview.news/p/eleven-lawsuits-by-detransitioners?r=25omz6&utm_campaign=post&utm_medium=web Note: This newsletter states that in addition to the eleven public lawsuits listed in the endnote above, six private detransitioner lawsuits have been filed.

[55] State of Rhode Island Superior Court. Isabelle M. Ayala v. American Academy of Pediatrics, et al. Case Number: PC 2023-0542B. Submitted 23 October 2023. https://dw-wp-production.imgix.net/2023/10/Ayala-v-AAP-Complaint_stamped.pdf

[56] Mason, Julia. “Saving Child Medicine from Gender Ideology with Julia Mason.” Interview by Benjamin Boyce for the Benjamin A. Boyce Podcast. YouTube, 3 October 2022. https://www.youtube.com/watch?v=3iAd6tSzSYE (minutes 33 to 38:30 and minutes 50:09 to 52:45).

[57] Mason, Julia, and Leor Sapir. “The American Academy of Pediatrics’ Dubious Transgender Science.” Wall Street Journal, 17 August 2022. https://www.wsj.com/articles/the-american-academy-of-pediatrics-dubious-transgender-science-jack-turban-research-social-contagion-gender-dysphoria-puberty-blockers-uk-11660732791

[58] Rafferty, Jason. “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents.” Pediatrics, vol. 142, no. 4, 2018, pp. 1-14, https://publications.aap.org/pediatrics/article/142/4/e20182162/37381/Ensuring-Comprehensive-Care-and-Support-for (sidebar, page 1).

[59] Sulaski Wyckoff, Alyson. “AAP reaffirms gender-affirming care policy, authorizes systematic review of evidence to guide update.” American Academy of Pediatrics, 4 August 2023, Press release, https://publications.aap.org/aapnews/news/25340/AAP-reaffirms-gender-affirming-care-policy?autologincheck=redirected

[60] 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 – unofficial translation. Palveluvalikoima Tjänsteutbudet, 2020, pp 1-11 https://segm.org/sites/default/files/Finnish_Guidelines_2020_Minors_Unofficial%20Translation.pdf (page 8). Note: I found the link for this report at the bottom of this webpage: https://segm.org/Finland_deviates_from_WPATH_prioritizing_psychotherapy_no_surgery_for_minors

[61] Care of Children and Adolescents with Gender Dysphoria Summary of National Guidelines. Socialstyrelsen The National Board of Health and Welfare, Dec. 2022, pp. 1-6 https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/kunskapsstod/2023-1-8330.pdf  (page 3). Quote: “At group level (i.e. for the group of adolescents with gender dysphoria, as a whole), the National Board of Health and Welfare currently assesses that the risks of puberty blockers and gender-affirming treatment are likely to outweigh the expected benefits of these treatments.”

[62] Interim Service Specification: Specialist Service for Children and Young People with Gender Dysphoria (Phase 1 Providers) Publication Reference: PR1937_i. NHS England, 20 Oct. 2022, pp. 1-26, ‌https://www.engage.england.nhs.uk/specialised-commissioning/gender-dysphoria-services/user_uploads/b1937-ii-specialist-service-for-children-and-young-people-with-gender-dysphoria-1.pdf (page 16). Quote: “Consistent with advice from the Cass Review highlighting the uncertainties surrounding the use of hormone treatments, NHS England is in the process of forming proposals for prospectively enrolling children and young people being considered for hormone treatment into a formal research programme with adequate follow up into adulthood, with a more immediate focus on the questions regarding GnRHa. On this basis NHS England will only commission GnRHa in the context of a formal research protocol.”

[63] Care of Children and Adolescents with Gender Dysphoria Summary of National Guidelines. Socialstyrelsen The National Board of Health and Welfare, Dec. 2022, pp. 1-6, https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/kunskapsstod/2023-1-8330.pdf (page 4). Quote: “The Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) concludes that existing scientific evidence is insufficient for assessing the effects of puberty suppressing and gender-affirming hormone therapy on gender dysphoria, psychosocial health and quality of life of adolescents with gender dysphoria [2]. Knowledge gaps need to be addressed and the National Board of Health and Welfare recommends that these treatments be provided in the context of research.”

[64] Below are quotes from three news sources suggesting that gender-affirming care reduces the risk of suicide.

1. 1. 1. Olson, Jeremy. “‘It Got Very Bad, Very Quickly’: Families with Transgender Kids Seek Refuge in Minnesota.” Star Tribune, 6 May 2023. https://www.startribune.com/minnesota-transgender-refuge-children-families-move-gender-affirming-care/600272910/ Quote: “An estimated 40% of transgender children have attempted suicide, which is one reason the American Academy of Pediatrics and the American Medical Association endorse gender-affirming care.”
      2. Ferguson, Dana, et al. “Minnesota to join at least 4 other states in protecting transgender care this year.” National Public Radio, 21 April 2023. https://www.npr.org/2023/04/21/1171069066/states-protect-transgender-affirming-care-minnesota-colorado-maryland-illinois Quote: “’Frequently, we will talk about gender-affirming care as life-saving health care. And we’re not saying that to be dramatic,’ says Dr. Angela Kade Goepferd, chief education officer and medical director of the Gender Health program at Children’s Minnesota. Kade Goepferd says kids who can’t access care ‘are at significantly higher risk of worse mental health outcomes, including ’”
      3. Davies, Tom. “Federal judge blocks much of Indiana’s ban on gender-affirming care for minors.” AP. 16 June 2023. https://abcnews.go.com/US/wireStory/federal-judge-blocks-indianas-ban-gender-affirming-care-100153581  Quote: “Indiana’s Republican-dominated Legislature approved the ban after contentious hearings that primarily featured testimony from vocal opponents, with many arguing the gender-affirming care lessened the risk of depression and suicide among transgender youth.” and,  “The ACLU had provided ‘evidence of risks to minors’ health and wellbeing from gender dysphoria if those treatments can no longer be provided to minors — prolonging of their dysphoria, and causing additional distress and health risks, such as depression, posttraumatic stress disorder, and suicidality,’ Hanlon said.”

[65] Evidence Review: Gender-affirming hormones for children and adolescents with gender dysphoria. NICE The National Institute for Health and Care Excellence, Oct. 2020, pp. 1-156. (page 14). Quote: “Results from 5 uncontrolled, observational studies suggest that, in children and adolescents with gender dysphoria, gender-affirming hormones are likely to improve symptoms of gender dysphoria, and may also improve depression, anxiety, quality of life, suicidality, and psychosocial functioning. The impact of treatment on body image is unclear. All results were of very low certainty using modified GRADE.”

[66] Evidence Review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria. NICE The National Institute for Health and Care Excellence, Oct. 2020, pp. 1-131. (page 13). Quote: “The results of the studies that reported impact on the critical outcomes of gender dysphoria and mental health (depression, anger and anxiety), and the important outcomes of body image and psychosocial impact (global and psychosocial functioning), in children and adolescents with gender dysphoria are of very low certainty using modified GRADE. They suggest little change with GnRH analogues from baseline to follow-up.”

[67] Baker, Kellan E., et. al. “Hormone Therapy, Mental Health, and Quality of Life Among Transgender People: A Systematic Review.” Journal of the Endocrine Society, 19 February 2021, pp. 1-16, https://doi.org/10.1210/jendso/bvab011  (page 13, Table 6).

[68] Ruuska, Sami-Matti, et al., “All-cause and suicide mortalities among adolescents and young adults who contacted specialised gender identity services in Finland in 1996–2019: a register study.” BMJ Mental Health, 17 February 2024, pp. 1-6, https://mentalhealth.bmj.com/content/ebmental/27/1/e300940.full.pdf (pages 1 and 5).

[69] Malone, William. “resisting adolescence  – episode 2.” Interview by Posie Parker for the Biological Woman’s Hour Podcast, SoundCloud, 26 May 2020 https://soundcloud.com/posie-parker/resisting-adolescence-episode-two (Minutes 15:43- 16:10). Quote: “In my private conversations, the majority of endocrinologists feel the same way that I do: alarmed at the widespread application of these interventions that don’t have proven benefit with known risk. Most are unwilling to speak out though because of … what happens in the current climate when you do speak out, … you’re targeted.”

[70] Malone, William. “The Hormone Health Crisis with Endocrinologist William Malone, MD.” Interview by Benjamin Boyce for the Benjamin A. Boyce Podcast. YouTube, 12 July 2019, https://www.youtube.com/watch?v=z4RYl75zdMY (minutes 45:10 to 45:48).