Our aim is to promote safe, compassionate, ethical and evidence-informed healthcare for children, adolescents, and young adults with gender dysphoria

Latest from SEGM

The study suggests that adolescent gender dysphoria may not persist for most
Disagreement about the permanence of gender-related distress experienced during adolescence is at the heart of the debate about the practice of youth gender transition. Those concerned about the practice point out that the endocrine and surgical interventions used to treat gender-related distress have lifelong, irreversible effects, and therefore should be delayed until maturity when there is more certainty that the trans identity will endure. The advocates of medical gender-affirmation for youth assert that gender dysphoria presenting in adolescence is usually permanent, and therefore the permanent nature of the treatments is not a concern.
Court documents offer a window into how this happens
The following publication appeared in the Economist online on June 29, 2024. It appeared in the United States section of the print edition under the headline “WPATH/Marking their own homework.” The article has been reproduced below fully, with permission.
WHO's inclusion of WPATH leaders involved in suppression of evidence sets a troubling context for the WHO effort
The World Health Organization (WHO) has reaffirmed its plans to issue a transgender and gender diverse (TGD) clinical practice guideline. Its prior announcements generated significant public concern from various stakeholders: clinician groups, LGBT groups, and parent groups. The heavy representation of members of WPATH on the WHO guideline development group has always been a concern, but this concern has now been increased by a new development. New evidence has emerged that two prominent WPATH members involved in the production of the WHO guidelines were directly involved in suppressing unfavorable evidence related to the availability of cross-sex hormones in the process of creating their…
The German guidelines' marked divergence from the Cass recommendations is explained by their failure to systematically appraise the evidence
In March 2024, the Association of Scientific Medical Societies in Germany (AWMF) published the final draft of the guidelines "Gender Incongruence and Gender Dysphoria in Childhood and Adolescence: Diagnosis and Treatment.” The guideline development process was formally led by the German Society for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy (DGKJP), with 26 other medical organizations from Germany, Switzerland and Austria participating. Germany's draft recommendations immediately drew international attention for their marked departure from England's Cass Report recommendations. The divergence between the two is remarkable. Having analyzed the two sets of…
The future of youth gender transitions in Germany is now in question, as the resolution clashes with the trans-affirmative draft guidelines released in March 2024
Earlier this week, the 128th German Medical Assembly, which comprises 250 delegates from 17 German medical associations, passed two important resolutions: to restrict puberty blockers, cross-sex hormones, and surgeries for gender-dysphoric youth under age 18 to controlled clinical trials; and to restrict self-ID laws to those over age 18.  The first resolution (Ic-48) focused on "gender-affirming care" for youth. The resolution, upvoted by the majority of physician delegates (120 votes in favor, 47 against, and 13 abstentions), stated: 
ESCAP calls for a return to "First, do no harm" in the use of experimental and unnecessarily invasive treatments for gender dysphoric youth
The European Society of Child and Adolescent Psychiatry (ESCAP) published a policy statement on child and adolescent gender dysphoria. ESCAP is a highly respected umbrella association of 36 Child and Adolescent Psychiatry societies (see Table 1). It enables collaboration among child and adolescent psychiatrists across Europe and holds a widely attended bi-annual professional conference for European child and adolescent psychiatrists.
Key take-aways from the single most notable event in the history of youth gender medicine of the last decade
The Cass Review of England’s gender services for children and young people, initiated four years ago, culminated earlier this week in the publication of the final 388-page report. The report was accompanied by 9 studies (8 of which were systematic reviews of evidence)  supporting the recommendations. Within hours, NHS England responded, thanking Dr. Hilary Cass and her team for “stepping up to lead such a complex review.” NHS England committed to following through on Dr. Cass’ recommendations, and acknowledged the national and international significance of this seminal work: “Your final report will not just shape the future of healthcare in this country for children and young people…
Right to "Open future" is most consistent with letting children become adults before proceeding with gender transition, conclude study authors
A new peer-reviewed article published in the Archives of Sexual Behavior examines the clinical and ethical implications of puberty blockers for children with gender dysphoria through the lens of “the child’s right to an open future.” As the authors explain, the open future principle refers to “rights that children do not have the capacity to exercise as minors, but that must be protected so they can exercise them in the future as autonomous adults.” It was introduced by Joel Fienberg, an American legal and political philosopher more than 40 years ago and has since been applied to multiple bioethical issues in pediatrics. 
NHS England will no longer allow puberty blockers for gender dysphoria, while the updated cross-sex hormones policy suggests a move toward caution as the country awaits the final Cass report due April 2024
In March 2024, NHS England (NHSE) updated its puberty blockers and cross-sex hormones policies for gender-dysphoric youth. The release of these policies coincides with the launch of the new service model, which will replace the Gender Identity Development Service (GIDS) at Tavistock as of April 1, 2024. The goal of the new service model is to provide holistic care and support for gender-distressed youth, shifting away from the “gender clinic” model of care focused on gender transition of minors.
Significant parallels between gender dysphoria and anorexia in teen girls calls for a nuanced and developmentally-informed approach
A new publication in Sexuologie (the journal of the German Society for Sexual Medicine, Sexual Therapy and Sexual Science/DGSMTW) takes on the issue of the sharp rise in transgender identification in adolescent females, which remains poorly understood. The authors, Korte and Gille, present an intriguing hypothesis for this novel phenomenon, comparing and contrasting gender dysphoria to anorexia nervosa, and finding a number of important similarities. The authors conclude that clinicians working with gender-dysphoric adolescents must familiarize themselves with the complex dynamics of female adolescent development, and that trans-affirmative medical interventions should not be considered…
The finding of low suicide rates and no evidence of benefits of gender reassignment continues to challenge the practice of youth transitions
Summary A recent study published in BMJ Mental Health, All-cause and suicide mortalities among adolescents and young adults who contacted specialised gender identity services in Finland in 1996–2019, analyzed overall mortality and suicide mortality among gender-referred young people in Finland over a 25-year time span (n=2,083; median age 19 years; median follow-up 5.7 years). The study defined young people as those referred to gender services under the age of 23.
WHO clarifies that “gender-affirmative care” is not supported by evidence in children and adolescents, but signals that it will recommend expanded hormone availability and legal recognition of self-determined gender for all others.
On January 15, 2024, the World Health Organization (WHO) issued an updated announcement regarding its plan to develop healthcare guidelines for “trans and gender diverse [TGD] people.” The earlier announcement, issued at the end of December 2023, generated much public concern. Various stakeholders—clinicians, LGBT groups/detransitioners,  parent groups,  and women’s rights champions—expressed alarm that WHO seemed to be proceeding on the basis of an unproven assumption that expanded access to gender-affirming hormones is universally beneficial. In addition, the groups also objected to the apparent WHO assumption that legal recognition of self-declared gender is a key human right and must be…
A biased panel composition and rushed process pose critical risk to WHO guideline credibility
On December 18, 2023, the World Health Organization (WHO) announced the final composition of the  Guideline Development Group (GDG), tasked with developing guidelines related to transgender health in 2024, and sought public comment. The guidelines will focus on 5 areas: provision of gender-affirming care, medical training, gender-affirmative health policies, “provision of health care for trans and gender diverse people who suffered interpersonal violence based in their needs”, as well as “legal recognition of self-determined gender identity.” The group is scheduled to meet at the WHO headquarters in Geneva on February 19-21, 2024 to evaluate and interpret the evidence, formulate guideline…
Medical, legal, and cultural debate over the practice of youth gender transitions has come to the birthplace of the Dutch Protocol
The Netherlands, like the rest of the Western world, has experienced an unprecedented increase in the number of youth seeking to undergo gender transition. Like the rest of the West, this sharp increase has been driven largely by adolescent females. Unlike the rest of the Western world, where this dramatic epidemiological shift has led to scientific debate about the practice of youth transition, the Netherlands practice has been insulated from scrutiny—until now.
Widespread methodological problems limit the reliability of “low transition regret” claims
Like all medical interventions, “gender-affirming” interventions are associated with a range of physical and mental health outcomes—both positive and negative. Regret and detransition are examples of negative outcomes. Proponents of youth gender transition assert that rates of regret and detransition are extremely low. These assertions are frequently cited in legal proceedings, medical journals, and even treatment recommendations. A new paper by Cohn, “The Rate of Detransition is Unknown,” reviews common limitations of “regret” studies and demonstrates that hormone discontinuation, detransition, and regret rates are largely unknown. It is important that clinicians, law makers, and those…
The journal of the Danish Medical Association "Ugeskrift for Læger" confirms the change has occurred quietly but resolutely
A major medical journal Ugeskrift for Læger,  the Journal of the Danish Medical Association, confirmed that there has been a marked shift in the country’s approach to caring for youth with gender dysphoria. Most youth referred to the centralized gender clinic no longer get a prescription for puberty blockers, hormones or surgery—instead they receive therapeutic counseling and support.
“Near-zero regret” findings among adults suffer from a critical risk of bias and have low applicability to youth
Recent research published in JAMA Surgery evaluated satisfaction and regret among individuals who had undergone chest masculinizing mastectomy at the University of Michigan hospital. The average patient age at the time of mastectomy was 27 years; no patients who were under age 18 were allowed to participate in the study.
The Society for Evidence-Based Medicine calls for an interim update based on existing systematic evidence reviews
We welcome the American Academy of Pediatrics (AAP) decision to update treatment recommendations for gender dysphoric youth based on the results of a systematic review of evidence the AAP plans to commission. This is an important step on the path to creating evidence-based treatment recommendations for managing youth gender dysphoria in the United States and Canada. However, we are concerned by the AAP decision to reaffirm its current policy for treating minors with puberty blockers, hormones and surgery pending the yet-to-be commissioned systematic review, and by the lengthy timeline for any updates to the policy this approach implies. Systematic reviews of evidence, when performed…
Elevated rates of suicide despite wide accessibility of gender transition interventions
A recently published study from Denmark compared the rate of suicide attempts, suicide-related deaths, non-suicide-related deaths, and all-cause mortality between non-transgender and transgender-identifying individuals. The study spanned 42 years, however the average follow-up for transgender-identified individuals was less than six years. The study found that transgender-identifying individuals in Denmark had significantly elevated rates of all four adverse outcomes. The absolute risk of death by suicide among transgender-identified individuals was estimated as 75 suicides per 100,000 patient-years (standardized adjusted rate). A clinician would need to treat 1,333 transgender-…
Detransitioners deserve comprehensive medical and supportive care
In a new peer-reviewed commentary published in the Journal of Sex & Marital Therapy, author, Dr. Sarah Jorgensen, argues that the medical community has a professional responsibility to recognize detransitioners as survivors of iatrogenic harm and provide them with the comprehensive medical and supportive care that they deserve. Jorgensen notes that proponents of gender-affirming medical interventions have attempted to downplay regret and detransition as vanishingly rare based on outdated studies that are not applicable to cohorts of adolescent trans identifying females presenting to gender clinics today. They refuse to admit that the gender-affirming model is failing some patients and…
A deeply problematic precedent that may lead to thousands of retractions
UPDATE 11/18/2023: Following a retraction by Springer, the research was re-published by the Journal of Open Inquiry of the Behavioral Sciences (JOIBS). The research underwent a new peer-review process, which resulted in some changes to the manuscript originally published by Springer.    In March 2023, the Archives of Sexual Behavior published a peer-reviewed paper, Rapid Onset Gender Dysphoria: Parent Reports on 1655 Possible Cases. As the title indicates, the paper examined 1,655 reports from parents who reported that their previously gender-normative teens developed transgender identities and described the context in which this occurred (typically, both social…
A nuanced look at detransition and implications for youth transitioning today
A new peer-reviewed article, “Transition Regret and Detransition: Meaning and Uncertainties," published in the Archives of Sexual Behavior, reviews clinical and research issues related to transition regret and detransition. The article emphasizes that “although recent data have shed light on a complex range of experiences that lead people to detransition, research remains very much in its infancy,” and there is currently “no guidance on best practices for clinicians involved in their care.”    The author, Dr. Jorgensen, notes that the term "detransition" can hold a wide array of possible meanings for transgender-identifying people, detransitioners, and researchers, leading…
The field of gender medicine must stop relying on social justice arguments and return to the time-honored principles of evidence-based medicine.
A new article in Springer’s Current Sexual Health Reports, “Current Concerns About Gender-Affirming Therapy in Adolescents,” provides an up-to-date overview of the current state of evidence about the practice of gender transition in youth in the Western world and discusses the international debates surrounding this controversial practice.
The following Economist article from April 5, 2023 has been reproduced fully, with permission
Prisha Mosley was 17 when she was first given testosterone in a clinic in North Carolina, after she had declared to her parents that she was a boy. She had struggled through her teen years with anorexia and depression after a sexual assault. Luka Hein had both breasts removed as a 16-year-old in Nebraska. Chloe Cole, in California, was a year younger when she had her double mastectomy. She had been on testosterone and puberty-blocking drugs since 13, also after a sexual assault.
Parents report a deterioration in children's mental health and intrafamilial bonds following gender-transition
A new study examining 1,655 parental reports lends further credibility to the rapid onset gender dysphoria (ROGD) hypothesis, first posited by Dr. Lisa Littman in 2018. The ROGD hypothesis suggests that the recent surge in transgender-identifying adolescents is explained, at least in part, by a rise in previously gender-normative teens who developed gender-related distress around or after puberty as a maladaptive coping mechanism. Opponents of the ROGD hypothesis claim that the surge is merely the result of greater acceptance of transgender identities by society, and hence, a greater willingness among “intrinsically transgender” adolescents to “come out.” If true, the ROGD hypothesis…
The study's conclusions and "clinical implications" are not supported by the data presented
A recent study published in The Journal of Sexual Medicine reported demographic and treatment trends among gender-dysphoric youth seeking evaluation and/or treatment at the Netherlands’ largest pediatric gender clinic in Amsterdam (VUmc) between 1997 and 2018. The study seemingly supports the emerging narrative that "gender-affirming" care for youth has been thoroughly tested over 2 decades; that the long-term trajectories of gender-transitioned youth are both well-understood and positive, as evidenced by virtually no detransition; and that in fact, many "transgender adolescents" do not want any medical interventions—but for those who desire them, puberty blockers, cross-sex hormones and…
A new study identifying flaws in gender medicine research demands urgent attention from the medical community
A new open-access publication, “The Myth of Reliable Research in Pediatric Gender Medicine,” focuses on the two Dutch studies that gave rise to “gender-affirmative” care for youth worldwide. The authors convincingly demonstrate that rather than "solid prospective research" or even the “gold standard” in research, as these studies are frequently described by the proponents of "gender-affirmative care," the Dutch research suffers from profound, previously unrecognized problems. These problems range from erroneously concluding that gender dysphoria disappeared as a result of “gender-affirmative treatment,” to reporting only the best-case scenario outcomes and failing to properly examine the…
A remarkable year for safeguarding of vulnerable youth
2022 has been nothing short of remarkable for the field of youth gender medicine. Two leading countries in pediatric gender transition, England and Sweden, stopped or announced the intention to stop transitioning youth as routine medical practice. And just as the year was drawing to a close, on December 30, 2022 a leading Dutch newspaper published the first-ever critical commentary focused on the Dutch gender clinic itself, questioning its continued support of medical interventions of the rapidly growing numbers of youths seeking gender transition.
A recent paper takes on 5 key faulty assumptions behind "gender-affirming" interventions for youth
The highly medicalized approach to managing gender distress in youth, integral to the “gender-affirmative” care model, rests on several key assumptions. Publications promoting “gender affirmation” of youth fail to explicitly call out these assumptions—or misrepresent these problematic assumptions as proven facts. A recent publication by J. Cohn examines several key assumptions that underlie an influential “pro-affirmation” paper published by the prestigious journal, Nature. These assumptions permeate much of the “gender-affirming” literature more generally, including the most recent publication by the same author. Cohn critically examines and cogently refutes each of the assumptions,…
A perfect storm environment for the placebo effect
To what extent are the purported short-term psychological benefits of “gender-affirming” care, reported by some recent studies conducted by pediatric gender clinics, due to the placebo effect, rather than the hormonal and surgical interventions themselves? This question is the focus of a new tour-de-force peer-reviewed publication in the Archives of Sexual Behavior by Dr. Alison Clayton.
It may not be in time to prevent lawsuits
Is Britain tiptoeing away from a medical scandal? Until recently, many gender specialists in the National Health Service (NHS) treated trans-identifying children by broadly following an “affirmative” approach which accepts patients’ self-diagnosis as the starting-point for treatment. That can mean the prescription of puberty blockers from early adolescence, followed by cross-sex hormones. But Britain now appears to be changing tack. Next spring the NHS will close its specialist youth gender-identity clinic in England, the Gender and Identity Development Service (GIDS) at the Tavistock foundation trust in London. It will be replaced by eight regional centres in which gender services will be…
The gender-clinic model of care has been replaced with holistic support and appropriate care
Following extensive stakeholder engagement and a systematic review of evidence, England’s National Health Service (NHS) has issued new draft guidance for the treatment of gender dysphoria in minors, which sharply deviates from the “gender-affirming” approach. The previous presumption that gender dysphoric youth under 18 need specialty “transgender healthcare” has been supplanted by the developmentally-informed position that most need psychoeducation and psychotherapy. Eligibility determination for medical interventions will be made by a centralized Service and puberty blockers will be delivered only in research protocol settings. With the new NHS guidance, England joins Finland and Sweden…
The following Economist article has been reproduced fully, with permission.
When Jane Clark’s 15-year-old daughter told her that she thought she might be gay, Dr Clark, a paediatrician who calls herself a “typical west-coast liberal”, said, “ok, great.” When the child a few months later said she thought she was non-binary, “I was, like, I don’t know what that means, but ok.” She found a gender therapist for her child, expecting a period of therapy.
The following leading article from The Times (July 29th, 2022) has been reproduced fully, with permission
The damage done is immeasurable. No one knows how years of ideological dogma, inappropriate treatment and a culpable failure to consider the overall mental welfare of the children treated by the Tavistock Clinic will affect the thousands referred to its Gender Identity Development Service. Yesterday the government thankfully brought the scandal to a swift halt. In the wake of a devastating report in March on the clinic’s reckless prescription of puberty blockers, ministers have shut it down altogether. Treatment of children questioning their gender identity will now be handled instead by established and respected regional children’s hospitals. Disbanding the Tavistock is not before time.
Treatment for gender dysphoria will be provided by established children's hospitals and will no longer be siloed under the "affirmative care" model
The UK’s National Health Service will close the world’s largest pediatric gender clinic, the Gender Identity Development Service in London (GIDS) often known as the Tavistock, after the NHS Trust which houses it.  An independent review condemned the clinic as “not a safe or viable long-term option” because its interventions are based on poor evidence and its model of care leaves young people “at considerable risk” of poor mental health. The clinic must close by spring 2023
The following Special Report from The Times (June 17th, 2022) has been reproduced fully, with permission
Since 2010, the number of teenage girls referred to the Tavistock Gender Identity Development Service has increased by 5,000 per cent. Now former patients and staff members are speaking out. For me it began with a graph. In 2017, I was shown a chart of children referred to GIDS, the Tavistock and Portman Trust’s Gender Identity Development Service clinic in northwest London. Overall case numbers had risen – from just 72 in 2009-10 to 1,807 in 2016-17 – but there was something more puzzling. Female referrals, once a fraction of males, now made up 70 per cent: from 32 to 1,265. The number of teenage girls with gender dysphoria (ie profound discomfort with their biological sex) had risen by 5…
A new study lends credibility to concerns that early social gender transition can lead to persistence of pediatric gender dysphoria
A recent study published in Pediatrics examined the 5-year gender identity development trajectory of transgender-identified children who underwent early social gender transition (SGT). The children were, on average, 6-7 years old at the time of SGT. Five years later, at the average age of 11-12, almost all—97.5%—continued to identify as transgender, including a small subset (3.5%) developing a non-binary identification. Only 2.5% of the children desisted from transgender identification by the end of the study period, and re-identified with their sex. Some of the recent news coverage of this study incorrectly stated that the study confirmed that children who claim a transgender identity…
"Gender-Affirming Care and Young People" contains a number of errors and misrepresentations
Last week, the U.S. Department of Health and Human Services (HHS) issued an official document entitled "Gender-Affirming Care and Young People". The document purported that the use of “gender-affirming” hormonal and surgical interventions for youth struggling with gender dysphoria is “crucial to overall health.” In light of the proposed rule announced by the HHS earlier this year mandating the provision of hormonal and surgical interventions, the debut of this official document carrying the official HHS seal is noteworthy. Below, we fact-check the accuracy of the claims made in the newly-released HHS document. We also reflect on the process used by HHS to arrive at the conclusion that the…
Reconsidering informed consent for trans-Identified children, adolescents, and young adults
Trans-identified youth present to clinicians as strongly desiring hormones and surgery. However, this conviction should not be confused with the capacity to carefully consider the consequences of gender transition, argues a recent article about informed consent in gender medicine, published in the peer-reviewed Journal of Sex…
Medical care of children and adolescents with transgender identity
The National Academy of Medicine in France has issued a press release in which it cautions medical practitioners that the growing cases of transgender identity in young people are often socially-mediated and that great caution in treatment is needed. The Academy draws attention to the fact that hormonal and surgical treatments carry health risks and have permanent effects, and that it is not possible to distinguish a durable trans identity from a passing phase of an adolescent's development. SEGM has translated the press release, which is provided in full below. Both the original press release in French, and its unofficial SEGM translation are appended.
February 2022 update
In February 2022, the Swedish National Board of Health and Welfare (NBHW) issued an update to its health care service guidelines for children and youth <18 with gender dysphoria / gender incongruence. This update contains 14 distinct “recommendations,” with justification for each, referencing a recently completed systematic review of evidence. Three of the recommendations provide guidance for social support for gender dysphoric youth and their families; nine focus on the assessment of gender dysphoria/gender incongruence; and two target hormonal interventions: puberty blockers and cross-sex hormones. Additional updates are anticipated later in 2022.
A recent systematic review of puberty blockers exemplifies problems in gender medicine research
Studies in the field of gender medicine are notoriously unreliable, plagued by small samples, lack of controls, confounding, and bias. This is true for even the “best” studies in the field,  such as the “Dutch study”— the foundation of treating gender dysphoric youth with hormones and surgery. While the Dutch protocol showed some positive results in the Netherlands, it could not be replicated in the world’s biggest pediatric gender clinic, the UK’s GIDS. Other studies, many making headlines, suffer from even more serious biases, limitations, and downright erroneous data analyses.
The suicide rate is higher than in the general population but much lower than implied by surveys
Adolescents who identify as transgender are vulnerable to suicidal thoughts and self-harming behaviors. This fact, frequently reported by the news media, is often used as the justification for the rapid provision of "gender-affirming" hormonal and surgical interventions to gender-dysphoric adolescents: “Fifty percent of transgender youth attempt suicide before they are at age 21,” declared the mother of Jazz Jennings, the most famous transgender youth in the English-speaking world. Although the elevated rate of suicidality in trans-identified youth is well-documented, a closer examination of the risk of suicide among trans-identified youth reveals a more complex picture.
SEGM critiques "Standards of Care" 8 for its lack of methodological rigor
The Society for Evidence-Based Gender Medicine (SEGM) welcomes WPATH SOC8’s acknowledgement of the profound shift in the incidence of gender dysphoria/gender incongruence and its presentation among youth, and the acknowledgement of the risk of inappropriate medical transition of youth. We also commend the increased focus on psychotherapy assessments, since gender incongruence in youth can arise from multiple causes and may have multiple paths to resolution.  At the same time, we are disappointed by the significant methodological limitations in the draft SOC8 guideline.
Therapist critiques "gender-affirmative" care model for youth
What happens when a young person's intensely experienced desire to undergo medical transition is granted, with minimal attention paid to the factors contributing to the development of gender dysphoria, and with no attempts to ameliorate the distress non-invasively first? A new publication, Gender Detransition, a Case Study by Lisa Marchiano, presents a case study of a young natal female detransitioner. This case study is an effort to elucidate the complex characteristics and issues involved in the desire for transition and detransition in the novel population of adolescents with post-puberty onset of gender dysphoria. Marciano observes the limitations of the "gender-affirmative" care model…
Psychologist advocates for psychotherapy rather than pharmacological and surgical interventions
Consistent with the principle, “First, do no harm,” in Clinical and Ethical Considerations in the Treatment of Gender Dysphoric Children and Adolescents: When Doing Less Is Helping More, psychologist David Schwartz, Ph.D. exhorts clinicians to treat children and adolescents with gender dysphoria (GD) using psychotherapy rather than pharmacological and surgical interventions. He asserts, “in the treatment of children and adolescents, no matter what the diagnosis, encouraging mastectomy, ovariectomy, uterine extirpation, penile disablement, tracheal shave, the prescription of hormones which are out of line with the genetic make-up of the child, or puberty blockers, are all clinical practices…
Australia and New Zealand College of Psychiatrists recognizes that gender dysphoria can arise from multiple causes
The Royal Australian and New Zealand College of Psychiatrists (RANZCP) released its first position statement addressing the mental health needs of people with Gender Dysphoria/Gender Incongruence in August 2021, which was followed by an update in September 2021. Prior to this, the college’s position in relation to Gender Dysphoria was contained within the position statement on LGBTQ mental health. This new statement is the first position statement released by a professional body, as far as we are aware, which does not specifically endorse a gender-affirming approach.
The Lancet debate on gender-dysphoric youth: getting the facts right
Recently, The Lancet published an editorial defending broad availability of medicalization of gender-dysphoric youth. The editorial was written in response to several US bills that aim to limit the use of hormones and surgery in minors. It asserted that hormonal and surgical interventions for gender dysphoric youth are proven treatments and that regret for gender transition is below 1%. A vigorous scientific debate ensued, revealing the deficiencies in these claims, and highlighting the importance of platforming debate in this contested area of medicine.
A new study suggests that detransitioners have complex problems not solved by transition and that the prevalence of detransition may be underestimated
A new study of individuals who medically or surgically transitioned and subsequently detransitioned, suggests that the rate of detransition may be significantly underestimated. According to the study, which examined the survey responses of 100 detransitioners, fewer than 1 in 4 notified their treating providers of the decision to stop or reverse their transition.
All but one clinic agree transitions should happen only in "exceptional cases" outside of clinical trials, as they await new official guidance due later this year
According to a recently published medical news article in Sweden, representatives of all of Sweden's six university clinics that treat children and young people with gender dysphoria participated in a meeting called by Sweden's National Board of Health and Welfare to discuss the approach to hormonal interventions for gender-dysphoric youth. This meeting followed an earlier announcement by the Karolinska's Astrid Lindgren Children's Hospital that it will no longer provide pediatric medical transition outside of strictly controlled clinical trials. The article reported that all but one pediatric gender clinic in Sweden have changed their protocols and no longer…
American Academy of Pediatrics annual 2021 conference blocks SEGM’s participation
Last week, the American Academy of Pediatrics (AAP) rejected SEGM’s application to share the latest evidence regarding the practice of pediatric gender transition at AAP's upcoming annual conference in Philadelphia in October 2021. This rejection sends a strong signal that the AAP does not want to see any debate on what constitutes evidence-based care for gender-diverse youth.
SEGM files an Amicus Brief with the US 9th Circuit Court of Appeals
The Society for Evidence-Based Gender Medicine (SEGM) has filed an Amicus Brief with the 9th Circuit Court of Appeals, challenging the position held by WPATH and set forth in WPATH’s and the Pediatric Endocrine Society’s Amicus Brief that mastectomies for gender-dysphoric adolescents are evidence-based.  SEGM recognizes the right of mature adults to undergo "gender-affirming" interventions despite the low quality of evidence (i.e., small study samples, weak study designs, very limited long term follow-up, etc.) on which these interventions are based. However, we are very concerned about applying what are experimental procedures to vulnerable youth, whose gender…
Finland prioritizes psychotherapy over hormones, and rejects surgeries for gender-dysphoric minors
A year ago, the Finnish Health Authority (PALKO/COHERE) deviated from WPATH's "Standards of Care 7," by issuing new guidelines that state that psychotherapy, rather than puberty blockers and cross-sex hormones, should be the first-line treatment for gender-dysphoric youth. This change occurred following a systematic evidence review, which found the body of evidence for pediatric transition inconclusive.  Although pediatric medical transition is still allowed in Finland, the guidelines urge caution given the unclear nature of the benefits of these interventions, largely reserving puberty blocker and cross-sex hormones for minors with early-childhood…
A recently-published rebuttal to the Endocrine Society's Position on transgender interventions
In December of 2020, the Endocrine Society, in partnership with the Pediatric Endocrine Society, released a Position Statement regarding transgender health. That position statement asserts that there is a biological underpinning to transgender identification and that hormonal and surgical interventions for those suffering from gender dysphoria are safe and effective. The statement additionally claims that such interventions are "standard of care." A recently published peer-reviewed letter to the editor of the Journal of Clinical Endocrinology and Metabolism (JCEM), an official journal of the Endocrine Society, argues that these positions are unsupported by current medical evidence.
A new study looks at detransition-related needs and support
Over the last few years, a growing community of detransitioners has formed online. Despite the visibility recently given to the topic in mainstream media, including a recent 60 Minutes episode featuring detransitioners and their stories, detransition is still a poorly understood phenomenon. A recent exploratory cross-sectional study aims to serve as a springboard for further academic research on the subject. It focuses particularly on uncovering the specific needs that detransitioners experience and the support - or lack thereof - that they receive. The study also provides information about the average age of transition, detransition, and the duration of transition among study participants.
SEGM answers questions about the state of North American gender care for children, adolescents and young adults
Following the 60 Minutes episode earlier this week, which highlighted the controversies surrounding medical interventions for gender dysphoric youth, SEGM has been receiving an increasing number of inquiries about the state of gender care for youth in the United States. One question in particular has been asked most frequently: how difficult or easy is it to obtain hormones and surgeries in the US? There are over 60 pediatric “gender clinics” in the US, according to the Human Rights Commission’s interactive map. However, the total number of clinics and medical offices that provide hormonal interventions to minors is likely much higher, and is currently estimated at over 300. We cannot speak…
Concerns over medical harm and uncertain benefits result in a major policy shift
Update May 08, 2021. The Karolinska Hospital in Sweden recently issued a new policy statement regarding treatment of gender-dysphoric minors. This policy, affecting Karolinska's pediatric gender services at Astrid Lindgren Children's Hospital (ALB), has ended the practice of prescribing puberty blockers and cross-sex hormones to gender-dysphoric patients under the age of 18.
After two years, up to a third of children have abnormally low bone density
Suppressing puberty in children suffering from gender dysphoria — by administering Gonadotropin-Releasing Hormone agonist (GnRHa) — entails several known risks. One is that patients could “end with a decreased bone density, which is associated with a high risk of osteoporosis” (Delemarre-van de Waal…
Weighing potential benefits against profound long-term uncertainties
In 2020, the UK National Institute for Health and Care Excellence (NICE) undertook two systematic evidence reviews of the use of GnRH agonists (also known as "puberty blockers") and cross-sex hormones as treatments for gender dysphoric patients <18 years old. These reviews were commissioned by NHS England, as part of a review of gender dysphoria healthcare led by Dr Hilary Cass OBE. These reviews, which were published earlier this week, make for sober reading. The reviews' major finding is that GnRH agonists lead to little or no change in gender dysphoria, mental health, body image and psychosocial functioning. All the studies evaluated had results of “very low” certainty, and were…
Gender dysphoria emerges in youth who have problematic developmental histories
It is a well-established observation that individuals suffering from gender dysphoria (GD) demonstrate an increased prevalence of mental health issues when compared to the general population. One theory that explains the link between GD and mental illness is the minority stress model. Gender-non-conforming and GD youth experience elevated rates of victimization, discrimination, and prejudice. According to the minority stress theory, these adverse experiences are the primary cause of the poorer mental health status of GD individuals. There are two issues which contradict the minority stress theory. First, evidence shows that mental health issues often precede the onset of gender identity…
Gender detransition, broadly defined as the interruption or reversal of a gender transition process, has acquired noticeable visibility in recent years. Those who detransition, commonly referred to as "detransitioners," have started to share their experiences on social media and other online platforms, raising substantial questions for clinicians working in the field of gender dysphoria. However, detransitioners are not a homogeneous population. As gender detransition garners formal recognition within the health community, there is also a need to increase awareness of the varying motives that might lead a person to interrupt or reverse their gender transition. Having a basic typology…
SEGM end-of-year review
The year 2020 has been pivotal in the field of gender medicine. Earlier this month, in a landmark decision, the UK High Court ruled that children under 16 are unlikely to be able to consent to the use of puberty blockers, which the Court deemed to be an experimental treatment. Rather than a “pause button,” the court recognized puberty blockers as the first step in a largely irreversible pathway of medical transition.
The following Economist article has been reproduced fully, with permission
In 2018 Andrea Davidson’s 12-year-old daughter, Meghan, announced she was “definitely a boy”. Ms Davidson says her child was never a tomboy but the family doctor congratulated her and asked what pronouns she had chosen, before writing a referral to the British Columbia Children’s Hospital (BCCH). “We thought we were going to see a psychologist, but it was a nurse and a social worker,” says Ms Davidson (both her and her daughter’s names have been changed).
SEGM position statement
The Society for Evidence-Based Gender Medicine (SEGM) maintains that treatments for gender-dysphoric people should be supported by high quality evidence. We commend the thorough process undertaken by the UK High Court to assess the ability of young people to consent to treatment that has serious side effects and lacks adequate supporting evidence. The UK High Court determined that the provision of puberty blocking medications (GnRHa) to stop normally-timed puberty in gender dysphoric young people is experimental (1). The judges recognized puberty blockers as the first step in a trajectory that almost invariably leads to later prescription of cross-sex hormones with irreversible…
SEGM clinicians examine a study purporting harms of psychotherapy
In September 2019, JAMA Psychiatry published an article, Association Between Recalled Exposure to Gender Identity Conversion Efforts and Psychological Distress and Suicide Attempts Among Transgender Adults. The article concluded that therapies that did not "affirm" an individual's transgender identity (which the article refers to as "gender-identity conversion efforts / "GICE") lead to severe distress and even suicide attempts. These findings have been used to promote legislative bans on non-affirmative therapies worldwide. Without a doubt, attempts to force a change in one’s gender identity have no place in the field of mental health. Yet, we have been growing increasingly…
Allowing scientific debate in transgender medicine improves evidence basis
In October 2019, the American Journal of Psychiatry (AJP) published a study from the Karolinska Institute in Sweden, and the Yale School of Public Health which reported that “gender-affirming" surgeries for gender dysphoric patients are associated with improved mental health outcomes (1). Looking at mental health utilization in the year 2015, a retrospective analysis showed that the more time passed since surgery, the fewer mental services were utilized by patients, with an average 8% reduction in mental health utilization for each year following surgery. From this, the study concluded that surgery has a beneficial effect on mental health, and that benefits continue to…

SEGM in Media

Gender medicine in the US: how the Cass review failed to land

The review by Hilary Cass, paediatrician and former president of the Royal College of Paediatrics and Child Health, was commissioned by the NHS and built on the findings of Cass’s 2022 interim report. Then, she found that the evidence underpinning the treatment intensive, “gender affirming” model of care for distressed young people was “limited” and “inconclusive.” The final report is even clearer: “The reality is that we have no good evidence on the long term outcomes of interventions to manage gender related distress.”

But in the United States, where the gender affirming model is the norm, the effect of Cass’s four year investigation and final report isn’t yet obvious. “Unfortunately, Cass does not seem to be penetrating the public consciousness,” says Zhenya Abbruzzese, cofounder of the four year old Society for Evidence Based Gender Medicine (SEGM), a group of researchers and clinicians that has pushed for systematic reviews and an evidence based approach.


Pediatric Transgender Care and the Contentious Rise of SEGM: The Society for Evidence-Based Gender Medicine is praised by some and vilified by others. Either way, it’s making waves.

...In October 2023, SEGM held its first official conference in New York, which brought together an array of high-profile speakers, such as Mikael Landén, a psychiatrist and researcher at Sweden’s Karolinska Institute, and Sallie Baxendale, a professor of clinical neuropsychology at University College London. Journalists from Canadian public radio attended, along with then-BBC Newsnight reporter Hannah Barnes, whose bestselling book “Time to Think” chronicled the rise and fall of the Tavistock gender clinic.

...Erica Anderson, a psychologist who is transgender and who has helped young people to transition, described SEGM as the most important group of clinicians and scientists working in youth gender medicine.

...Among those present at SEGM’s New York conference was Gordon Guyatt, a professor at McMaster University in Canada, and a founding figure in evidence-based medicine, a movement that seeks to bring well-designed research into clinical decision-making. Guyatt is among the experts developing systematic reviews sponsored by SEGM on topics including chest-binding and genital tucking, and puberty blockers and cross-sex hormones for people 25 and under.


The New York Times

It is especially hard for kids who are making decisions about their identities when those identities are still evolving. Many construct their lives around this new identity. To admit they have changed their minds, especially during the excruciatingly self-conscious period of adolescence, when they are deeply susceptible to peer judgment, is that much harder. The effects of medical transition — facial hair growth, breast growth or removal, vocal changes — are often irreversible. For some, it can feel like there’s no going back.

We do have some reliable data that indicate detransition rates are higher than transgender advocacy groups suggest. (The Society for Evidence-Based Gender Medicine, one of the most reliable nonpartisan organizations dedicated to the field, has a full explainer of the methodological problems with the studies that insist otherwise.)


The New York Sun

On Thursday, the Society for Evidence Based Gender Medicine, or SEGM, issued its second letter criticizing the WHO’s effort, critiquing the guidelines-development process as apparently flawed from the time of its quiet inception two to three years ago... SEGM, in its new letter, asserted that those original two WHO guidelines made claims, specifically that cross-sex hormone access by trans persons is universally beneficial and that legal recognition of persons’ self-declared gender is a human right, that were “poorly-evidenced.” SEGM criticized the organization for apparently treating those two fundamental questions as settled facts by simple virtue of their inclusion in such previous guidance and expressed an “overarching concern that the WHO may be inadvertently involved in the production of a biased guideline.” 


The Telegraph

Recently I attended a conference in New York, hosted by Society for Evidence Based Gender Medicine (SEGM), a US-based non-profit, where I was asked to give a presentation on ‘lessons from the largest youth gender clinic in the world’ – for that’s what GIDS was...The conference was attended by professionals from other youth gender clinics around the Western world, which – like GIDS – have also received a rapid increase in referrals. And, like GIDS, they have seen a significant shift in the demographics of the young people being referred. But clinics in other parts of Europe responded in a very different way... 

...As for the conference organisers, SEGM has been branded ‘anti-trans’ by some. I saw no evidence of this. The conference venue was kept secret to protect those taking part; some had stated on social media that they planned to disrupt the event...

...I am a cautious journalist. I’m sometimes criticised for it. I did my homework before agreeing to take part, and before the BBC, as my then employer, gave me permission to do so. Members of the organising committee answered every question I had, including who funded them. And it’s not ‘far-Right, Christian evangelicals’. Faith was entirely absent from the conference. Most attendees work, or previously worked, directly with gender-questioning children. Hundreds, if not thousands, of them. Others were academics and experts in evidence-based medicine. Whatever anyone present at the conference thought about the best way to help gender- questioning youth, everyone agreed that they deserved good evidence-based care.



For two years in a row, AAP members submitted formal resolutions to the executive board asking “that the academy commit to the principles of evidence based medicine by eschewing narrative and other types of non-systematic reviews as the basis for its recommendations” and either use existing systematic reviews or commission its own.

A resolution submitted in April with two dozen signatories also asked that an “urgent statement” be made urging paediatricians “to exercise extreme caution in transitioning minors with hormones and surgeries pending the results.”

The lead author of these resolutions, Julia Mason, a paediatrician in Gresham, Oregon, and a founder of the Society for Evidence-Based Gender Medicine, told The BMJ she is “gratified” that AAP is “making a commitment to look at the evidence” but is “disappointed they are not taking a precautionary approach.”

AAP announced that its policy update process will be “transparent and inclusive,” and will “invite members and other stakeholders to share input.”

Mason said, “I’m hoping that means that they will include clinicians with different views, detransitioners, and parents.”


The New York Times

In June, England’s National Health Service announced that it would restrict the use of puberty blockers to clinical trials because “there is not enough evidence to support their safety or clinical effectiveness as a routinely available treatment.” Last year, Sweden’s national health care oversight body similarly determined that, on the basis of its systematic review, “the risks of puberty-inhibiting and gender-affirming hormone treatment for those under 18 currently outweigh the possible benefits.”

In the United States, a small group of pediatricians has pushed for a similar review from the A.A.P., one of the few institutions with enough centralized power to influence health care practices. Dr. Julia Mason, a pediatrician in Gresham, Ore., co-founded a group called the Society for Evidence-Based Gender Medicine that has been highly critical of gender treatments for minors. Since 2020, she said, she has unsuccessfully lobbied the academy’s leadership to commission a systematic review. Dr. Mason said she was pleased the group finally decided to take a close look at the data. “We are making strong recommendations based on weak evidence,” she said.


The Economist

The Dutch team’s approach was deliberately conservative. Patients had to have suffered from gender dysphoria since before puberty. Many of today’s patients say they began to suffer from dysphoria as teenagers. The Dutch protocol excludes those with mental- health problems from receiving treatment. But 70% or more of the young people seeking treatment suffer from mental-health problems, according to three recent papers looking at patients in America, Australia and Finland.

Despite the protocol’s caution, says Will Malone of the Society for Evidence-Based Gender Medicine, an international group of concerned clinicians, the reality is often the reverse, especially in America, with mental-health issues becoming a reason to proceed with transitions, rather than to stop them. 


The Free Press

I spoke to Dr. William Malone, an endocrinologist and a board member of the Society for Evidence-based Gender Medicine about the use of puberty blockers in young people. He says we don’t know enough about their long-term effects. “A child on blockers is halted in physical and likely emotional maturity,” he said. “Within a year or two, their peers will be profoundly different, and they become out of sync. Puberty is not just a physical event, it’s a psychosocial event with your peers. There is brain development that occurs. Blocking puberty likely has important implications for functionality as an adult.” 


Kaiser Health News

Even leaders of the Society for Evidence-based Gender Medicine, who are wholly skeptical of the acceleration in gender-affirming care, said ‘it is not accurate to say that the Biden administration is pushing these interventions on kids.’ ‘Presumably, children don’t read the statements by the administration endorsing gender-affirming care,” a society spokesperson said. "We find the politicization of transgender health deeply problematic and unhelpful. Unfortunately, much of the U.S. has taken a politicized approach, on both sides of the debate.’”



Five AAP members, which has a total membership of around 67,000 pediatricians in the United States and Canada, this year penned Resolution 27, calling for a possible update of the guidelines following consultation with stakeholders that include mental health and medical clinicians, parents, and patients "with diverse views and experiences." ... This year, the AAP sent an email to members stating it would not allow comments on resolutions that had not been "sponsored" by one of the group's 66 chapters or 88 internal committees, councils, or sections. ... Julia Mason, MD, a board member for the Society for Evidence-based Gender Medicine (SEGM) and a pediatrician in private practice in Gresham, Oregon, says an AAP chapter president agreed to second Resolution 27 but backed off after attending a different AAP meeting. Mason did not name the member.


The Economist

“William Malone, an endocrinologist with the Society for Evidence-based Gender Medicine, a non-profit group, sees parallels with previous medical scandals, not least the opioid crisis. There is a mix of “Big Pharma, a vulnerable patient population, and physicians misled by medical organisations or tempted by wealth and prestige”, he says. But now there is gender-identity ideology on top. “We are completely saturated with corporate influences and lobby groups,” says Dr Malone. “The only way they will be halted is if a massive number of people are harmed and they get together to sue the people who harmed them.””


Sharp Increase in Incidence of Gender Dysphoria in Children and Young People

Historically, the small numbers of children presenting with gender dysphoria were primarily prepubescent males. In recent years, there has been a sharp increase in referrals of adolescents, and particularly adolescent females, to gender clinics. Many do not have a significant history of childhood gender dysphoria and a number suffer from comorbid mental health issues and neurodevelopmental conditions such as autism (ASD) and Attention-Deficit/Hyperactivity Disorder (ADHD). The reasons for these changes are understudied and remain poorly understood.

Childhood-onset gender dysphoria has been shown to have a high rate of natural resolution, with 61-98% of children reidentifying with their biological sex during puberty. The research into the course of gender dysphoria desistance among the cohort presenting with adolescent-onset gender dysphoria is still in its infancy, due to the novelty of this presentation. However, recent research from the UK clinic population suggests that 10-12% of youth may be detransitioning within 16 months to 5 years of initiating medical interventions, with an additional 20-22% discontinuing treatments for a range of reasons. The researchers noted that the detransition rate found in the recently-presenting population raises critical questions about the phenomenon of "overdiagnosis, overtreatment, or iatrogenic harm as found in other medical fields." U.S. data suggest that the rate of medical detransition has reached ~30%.


SEGM on Twitter

Treatment of Gender-Diverse Youth

A growing chasm between North America and Europe 

Historically, medical interventions to achieve the appearance of the desired sex were reserved primarily for adults with long histories of dysphoria. Such interventions were preceded by a prolonged engagement with the patient, including thorough psychological assessments. While objective population-level data of adult gender transitioners show persistent mental health struggles and sharply elevated mortality and morbidity, subjective patient-reported outcomes suggest low regret rates. Unfortunately, "regret" studies routinely fail to get in touch with 20-60% of the transitioned patients, leaving unanswered questions about the substantial number lost to follow-up. 'Regret" studies also suffer from other significant limitations. However, there is little reason to doubt that a number of adult transitioners, having made an informed decision regarding the balance of  benefits, harms, and uncertainties, live rewarding lives.

However, around 2010's, there was a marked change in the approach to the management of gender dysphoria, particularly for gender-dysphoric youth. A number of countries in Western Europe, North America, and Australia, began to promote the "gender-affirmative" model of care for youth. Under this model of care, young people presenting with gender dysphoria or asserting a transgender identity are affirmed in their desire to undergo gender transition, and are provided with "barrier-free" hormonal and surgical interventions. While mental health professionals are often involved, their role is typically limited to preparing the young person for gender transition, regardless of any co-occurring mental health challenges or whether there was a relatively recent history of transgender identification. As such, the provision of medical intervention now happens with a much-reduced psychological assessment.

In the last 36 months, a growing number of Western countries have recognized the significant concerns with the "gender-affirmative" model of care, which became visible, in part, due to the growing voices of detransitioners and regretters coming from the novel population of gender-dysphoric youth. After completing systematic reviews of evidence, which showed that the risk-benefit ratio of youth transitions ranges from uncertain to unfavorable, these countries have begun to sunset the "gender-affirmation" practice in favor of an approach that favors psychosocial interventions as the first, and usually the only line of treatment available to most minors.

As of the current writing, the following countries have made sharp reversals of their previous "gender affirmation" practices or have signaled an intention to do so in the near future:

  • Sweden has made the decision to no longer offer gender transition to minors outside of research settings, and restricted eligibility to the "classic" early childhood onset of gender dysphoria. All others are to be treated with psychosocial support and psychotherapy, with a focus on accepting and thriving in natal puberty.
  • Finland has sharply restricted eligibility for gender transition to minors with a classic, early childhood-onset of gender dysphoria and no mental health comorbidities, and stated that psychotherapy should be the first line of treatment.
  • NHS England's new interim clinical policy finalized in March 2024 states that puberty blockers for gender dysphoria will no longer be available as part of general medical practice. Whether or not administration in research settings will be feasible remains to be determined. This followed an extended consultation period on the draft recommendations released in 2023. On March 21, 2024, the NHS also updated its policy on cross-sex hormones for youth, removing the requirement of puberty blockers as a prerequisite step for cross-sex hormone treatment, presumably to make two policies better aligned (since puberty blockers will no longer be available). The final Cass Report was published in April 2024. While the NHS England's policy to decommission puberty blockers as a treatment for youth gender dysphoria is likely final, its cross-sex hormones policy will likely be updated to bring it in line with the Cass Report's recommendations that cross-sex hormones for youth 16+ should be used with "extreme caution." SEGM's analysis concluded that the report signaled the end of the era of "gender-affirmative," gender-clinic-led model of care in England, with significant worldwide implications. 
  • Following the Cass Report, Wales and Scotland joined England in stopping new prescriptions of puberty blockers as a treatment for gender dysphoria in youth <18. Scotland's policy goes even further than England's. While in England, cross-sex hormones can still be prescribed "around the patient's 16th birthday," they cannot cannot be accessed in Scotland until a patient is 18.
  • Denmark has restricted eligibility for puberty blockers and cross-sex hormones, currently transitioning only 6% of youth referrals whose gender dysphoria is most consistent with the classic "Dutch" presentation (early childhood onset that intensified in adolescence, but otherwise uncomplicated by mental illness). This change in practice predated a change to treatment guidelines, which will be updated later this year.
  • Norway's Healthcare Investigation Board (NHIB/UKOM) has deemed puberty blockers, cross-sex hormones & surgery for children & young people experimental, determining that the current “gender-affirmative” guidelines are not evidence-based and must be revised. Norway's public health authority has signaled an intention to respond to UKOM's concerns with an adjustment to the current treatment guidelines.

Other countries are seeing growing debate:

  • The official journal of the German Medical Association published an article on the controversies in youth gender transition, stating that "the scientific evidence that these therapies are more beneficial than harmful is not as robust as has long been proclaimed." The article discussed the deficiencies in the evidence, noted that countries that were among the first to implement the practice of youth gender transition "are rowing back," and raised questions about implications for Germany's policy. A key German-language systematic review (with an English-translated appendix) updated the NICE systematic reviews and concurred with the findings concerning very low certainty of evidence. At the same time, the Association of the Scientific Medical Societies in Germany completed a "consensus" guideline that ignores the systematic reviews of evidence and promotes youth transitions. The final draft of the guideline is in the comment period through April 19, 2024, but it is not open to comment to anyone but the members of the societies who participated in the guideline creation. The draft, which is highly "gender-affirmative" in its recommendations, and the lack of transparency in the comment period, suggests that Germany may find itself at odds with the new focus on creating high-quality, evidence-based guidelines in the space of youth gender medicine.
  • France's National Academy of Medicine has signaled that work is underway to address the emerging issues with medial "gender affirmation" in minors.
  • Belgium's Director of Cochrane Belgium has expressed public concerns that puberty blockers are experimental and that the treatment guidelines promulgated by WPATH are not evidence-based. However, it is not clear whether the Belgium health authority plans to act on these concerns.
  • The Royal Australian and New Zealand College of Psychiatrists (RANZCP) acknowledged that "evidence and professional opinion is divided as to whether an affirmative approach should be taken in relation to treatment of transgender children or whether other approaches are more appropriate." New Zealand delayed its release of evidence review and recommendations for the use of puberty blockers, citing, in part, the Cass Report and the need to consider its findings and recommendations.
  • In the Netherlands, Amsterdam UMC, the clinic that pioneered the Dutch Protocol, has responded to the Cass Report. The response indicated that the Dutch 2018 treatment guidelines are currently undergoing revision. It is apparent that the international debate about youth transitions has reached the Netherlands.

In the meantime, in North America:

  • Florida has become the first state to have its public health authority disallow medical transitions for youth under 18 (while "grandfathering" existing cases).
  • In addition, a number of individual states have begun to pass laws to ban gender reassignment of minors, which have proven contentious.
  • At the Federal level the US continues to assert that "gender-affirming" care is safe and effective.
  • The Endocrine Society's President recently went on record asserting that gender transition of minors is a proven evidence-based practice. A letter from prominent clinicians involved in treatments of gender-dysphoric youth and evaluation of the outcomes sharply disagreed with such an assessment and called for the medical societies to "align their recommendations with the best available evidence—rather than exaggerating the benefits and minimizing the risks."
  • Most recently, the American Academy of Pediatrics (AAP) finally conceded it was time to conduct an independent review of the evidence and update its guidance, but it has already presaged the review's conclusion, which is that it will support the current pro-affirmation AAP position. This contradicts findings of multiple systematic reviews of evidence that found the benefits of gender transition for minors are highly uncertain, while the risks may be significant. Specifically, if the Endocrine Society's treatment guidelines for gender-dysphoric youth are followed, a minor's future sterility is likely. Other health risks include compromised bone health, altered brain development, cardiovascular complications, and a number of other, as yet unknown, risks.

The Dutch Protocol

The practice of medically transitioning minors, currently referred to as "gender-affirmative care," began to gain momentum following a single-site study in the Netherlands. Previously, gender transition was available only to mature adults, with the average age of transition frequently in the 30's. However, it was noted that the results of adult transitions were frequently disappointing, which was believed to be explained by unsatisfactory cosmetic outcomes, particularly for males, who had a "never disappearing masculine appearance." in the 1990's, the Dutch clinicians began to experiment with transitioning minors using endocrine interventions with the hope that a better cosmetic outcome would also lead to better mental health ones. The results of the innovative Dutch experiment, which has become known as "the Dutch Protocol," were documented in two publications: the 2011 study, which reported on cases who underwent puberty blockade, and the 2014 study, which reported on a subset of the cases who completed surgeries, including the removal of ovaries and testes upon reaching the age of 18.

The youth in the Dutch study reported high levels psychological functioning at 1.5 years after surgery, the study end point. However, both of the studies suffer from a high risk of bias due to their study design and suffer from limited applicability to the populations of adolescents presenting today  According to a recently-published overview of the Dutch protocol, the interventions described in the study are currently being applied in the way there were not intended. Specifically, adolescents who were not cross-gender identified prior to puberty, who have significant mental health problems, as well as those who have non-binary identities are now commonly treated using endocrine and surgical interventions described by the Dutch—yet all of these presentations were explicitly disqualified from the Dutch protocol.

The study itself suffers from significant limitations, ranging from a weak study design, only marginal improvements in psychological function, and number of under-reported adverse health events that occurred over the course of they study (including 1 case of death and 3 cases of severe morbidity). Researchers have also questions the validity of the gender dysphoria resolution reported by the Dutch, in light of their unusual handling of the gender dysphoria scale. Despite these limitations, the Dutch clinical experiment has become the basis for the practice of medical transition of minors worldwide and serves as the basis for the recommendations outlined in the 2017 Endocrine Society guidelines and has given rise to the so-called "gender affirmative" model of care for youth, which requires access to puberty blockers, hormones, and potentially surgery.

The medical pathway of the Gender-
Affirmative model consisting of...

  • Puberty blockers (GnRHas)
  • Lifelong cross-sex-hormones
  • Mastectomy or breast implants
  • Removal of ovaries or testes
  • Hysterectomy
  • Surgical removal and revision of sex organs

Hormonal & surgical interventions
can lead to:

  • Irreversible physical changes
  • Medical complications/ drug side effects
  • Surgical complications
  • Infertility
  • Arrest of a normal developmental process (puberty)

Multiple studies have found associations:

  • Bone/skeletal impairments
  • Cardiovascular complications
  • Premature death
  • High rates of post-surgery suicide

...is based on a single Dutch study:

  • 55 subjects (only 40 with complete data)
  • 100% had childhood-onset gender dysphoria  (no adolescent-onset gender dysphoria cases)
  • Only 1.5 year post-surgery follow-up at an average age of under 21
  • No control group
  • No physical health effects evaluation
  • One adolescent died as a result of post-operative complications. Several others could not pursue treatment due to new health issues arising following hormonal administration
  • Unchanged or worsening gender dysphoria and body image difficulties while on puberty blockers, especially among natal adolescent females

Despite the uncertainties and poor evidence, hormonal and surgical interventions are being scaled up. They go beyond the experimental “Dutch protocol” by:

  • Encouraging early social transition, explicitly discouraged by the Dutch protocol
  • Being applied to young people with adolescent-onset gender dysphoria, a population not included in the Dutch study

We agree with the concerns voiced by the recent publication, "Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults," that the Dutch studies have been misunderstood and misrepresented as providing evidence of the safety and efficacy of hormonal and surgical "gender-affirming" interventions for all youth. It is important that both the strengths and the weaknesses of these studies are thoroughly understood, as these two studies represent the best available evidence behind the practice of pediatric gender transition. You can read more about the strengths and limitations of the Dutch studies here

Need for Caution and Better Research

The history of medicine has many examples in which the well-meaning pursuit of short-term relief of symptoms has led to devastating long-term results; for example the past use of thalidomide, lobotomies, and the recent opioid epidemic. The "gender affirmative" model commits young people to lifelong medical treatment with minimal attention to the etiology of their conditions, and the psychosocial factors contributing to gender dysphoria. This model dismisses the question of whether psychological therapy might help to relieve or resolve gender dysphoria and provides interventions without an adequate examination.

We are asking clinicians and researchers to halt this uncontrolled experimentation on youth and replace it with a supportive framework of research that generates useful evidence about the etiology of gender dysphoria and the benefits and harms of various interventions. We need to know:

Which factors contribute to the development of gender dysphoria?

Which are the most effective interventions in gender dysphoria?

What are the long-term outcomes of those interventions?

We propose that, in view of the current dearth of evidence, the application of the model to children, adolescents, and young adults is unjustified outside of research settings. Further, patients, families, and clinicians cannot make fully informed healthcare decisions without knowing the likely benefits and harms of the various interventions and without appreciating the full extent of the unknowns.

Contribute to Our Cause

SEGM promotes safe, compassionate, ethical and evidence-informed healthcare for children, adolescents, and young adults with gender dysphoria. You can donate via GoFundMe, by credit card, or by mailing us a check.

SEGM is a registered 501(c)(3) nonprofit organization. Contributions to SEGM are tax-deductible to the extent permitted by law. SEGM's tax identification number is 84-4520593.

Donate via GoFundMe

Healthy Kids, Healthy Communities

Donate by credit card

Subscribe to our newsletter

If you share our concerns and would like to get updates about SEGM's work, please provide your email.

Contact 1

Your email will be stored securely and will never be shared with third parties.
You will be able to unsubscribe at any time.