1. The use of puberty blocker drugs or cross-sex hormones to treat gender dysphoria has been described as experimental by researchers and is not approved by the Food and Drug Administration (FDA); 8
2. The use of puberty blocker drugs or cross-sex hormones to treat gender dysphoria has been recognized by medical authorities in Europe, after independent reviews, to be experimental or lacking sufficient evidence and has been substantially restricted in countries such as Sweden, Finland, Norway, and the United Kingdom; 9
3. The U.S. Agency for Healthcare Research and Quality has determined, “There is a lack of current evidence-based guidance for the care of children and adolescents who identify as transgender, particularly regarding the benefits and harms of pubertal suppression, medical affirmation with hormone therapy, and surgical affirmation”; 10
4. A study spanning 5 decades of almost 5,000 transgender people who had received cross-sex hormones, regardless of treatment type, nevertheless showed a “twofold increased mortality risk,” which “did not decrease over time”; 11
5. An article in the International Review of Psychiatry found that, according to ten different studies, the vast majority of children, 85.2%, experiencing gender dysphoria grew to become comfortable with their natal sex, and the Endocrine Society found that “the large majority (about 85%) of prepubertal children with a childhood diagnosis did not remain GD/gender incongruent in adolescence”; 12
6. A scientific article in the Journal of Infant, Child, and Adolescent Psychotherapy concluded that “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 which run an unacceptably high risk of doing harm”;13
7. Sweden’s National Board of Health and Welfare (“NBHW”) recently declared that, at least for minors, “the risks of puberty suppressing treatment with GnRH-analogues and gender-affirming hormonal treatment currently outweigh the possible benefits”; 14
8. A systematic review of the evidence by researchers in Europe regarding natal boys concluded that there is “insufficient evidence to determine the efficacy or safety of hormonal treatment” and that certain hormonal interventions can potentially cause or worsen depression; 15
9. One scientific study noted that an individual whose friend identifies as transgender is “more than 70 times” as likely to similarly identify as transgender, suggesting that many individuals may “incorrectly believe themselves to be transgender and in need of transition” because of social factors”; 16
10. A follow-up study recently determined, “Youths with a history of mental health issues were especially likely to have taken steps to socially and medically transition”; 17
11. A study of 1,655 parental reports found that “parents tended to rate their children as worse off after transition” and “that parents believed gender clinicians and clinics pressured the families toward transition”; 18
12. The FDA has issued a warning that puberty blockers can lead to brain swelling and blindness; 19
13. Puberty is associated with profound developmental maturation of the brain, and researchers have expressed concern that interruption of normally timed puberty may therefore be harmful to the brain; 20
14. Multiple observational studies conclude that nearly all children prescribed puberty blockers for gender dysphoria have later been prescribed cross-sex hormones. For example, an independent review of gender transition interventions based on data from multiple countries determined that “almost all children and young people who are put on puberty blockers go on to sex hormone treatment”; 21
15. After performing a systematic review, the Endocrine Society was unable to draw any conclusions on whether hormone therapy reduces death by suicide among individuals identifying as transgender; 22
16. A summary of available evidence written by medical societies “from around the globe” found that “there are no proven methods to preserve fertility in early pubertal transgender adolescents”; 23
17. Researchers have suggested that allowing a child to go through puberty without medical intervention may resolve gender dysphoria, whereas puberty suppression may improperly influence and worsen gender dysphoria; 24
18. Puberty suppression presents a risk of stunted growth and failure to attain normal peak bone density; 25
19. There is a lack of understanding in the medical community of the causes of gender dysphoria, as well as an admission that more research is needed to fully understand the effects, especially long-term effects, of puberty suppression and cross-sex hormone treatment; 26
20. A significant number of children and adolescents who begin gender transition interventions desist in their desire to transition, although the actual number is unknown because of low rates of follow up; 27
21. The Endocrine Society has acknowledged that children experiencing gender dysphoria are more likely to identify with their natal sex if they do not socially transition; 28
22. The World Professional Association for Transgender Health (“WPATH”) has acknowledged, “In most children, gender dysphoria will disappear before, or early in, puberty”; 29
23. Many medical, hormonal, or surgical transition interventions are irreversible. 30
Sources:
8 Baker et al., Hormone Therapy, Mental Health, and Quality of Life Among Transgender People: A Systematic Review, J. of the Endocrine Soc., 2021, Vol. 5, No. 4, 1-16, pp. 12-13 (acknowledging the systematic review was hindered by “[u]ncontrolled confounding,” “potential bias,” absence of specific validation for measuring psychological outcomes, “[i]nconsistency in identification of appropriate general population norms,” “publication bias,” omission of certain “potentially relevant studies,” and inability to “quantitatively pool[] results” leading to the conclusion “[m]ore research is needed”); Coleman et al., SOC 7, p. 20 (WPATH noting “the long-term effects” of puberty suppression “can only be determined when the earliest-treated patients reach the appropriate age”); see also Hruz et al., Growing Pains: Problems with Puberty Suppression in Treating Gender Dysphoria, The New Atlantis, Number 52, Spring 2017 pp. 6-7, 14-15, 18 (noting “whether blocking puberty is the best way to treat gender dysphoria in children remains far from settled…a drastic and experimental measure…not well founded on evidence”); Abbruzzese et al., p. 2 (noting the “key problem” is “not the lack of research rigor in the past—it is the field’s present-day denial of the profound problems in the existing research, and an unwillingness to engage in high quality research requisite in evidence-based medicine”).
9 See e.g., Gauffin et al., “Guideline Regarding Hormonal Treatment of Minors with Gender Dysphoria at Tema Barn - Astrid Lindgren Children’s Hospital (ALB),” 2021, (citing SBU (Swedish Agency for Health and Technology Assessment and Assessment of Social Services), “Gender Dysphoria in Children and Adolescents - An inventory of the literature” report 307, Record Number SBU 2019/427) (noting “low quality evidence” and “very little knowledge” about effects and safety); “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,” p. 6 (noting “as far as minors are concerns, there are no medical treatment that can be considered evidence-based”); Debra Soh, “Norway offers a step forward in eliminating gender ideology,” Washington Examiner, March 13, 2023, https://www.msn.com/en-us/health/other/norway-offers-a-step-forward-ineliminating-gender-ideology/ar-AA18yJkN (noting Norwegian Healthcare Investigation Board no longer considers its guidelines for “gender-affirming care” for minors to be evidence-based); Biggs, “The Tavistock’s Experiment with Puberty Blockers,” version 1.0.1, July 29, 2019, p. 3 (noting puberty suppressing drugs have “never been licensed for [gender dysphoria] anywhere in the world”); see “Medicine and Gender Transidentity in Children and Adolescents,” French National Academy of Medicine, Feb. 25, 2022 (French National Academy of Medicine noting “a great medical caution must be taken in children and adolescents, given the vulnerability, particularly psychological…and the many undesirable effects, even serious complications, that some of the available therapies can cause”); see also Abbruzzese et al., p. 1 (noting the field of youth gender-affirming care tends to exaggerate what is known about the benefits of care while “downplaying the serious health risks and uncertainties,” which narrative has “failed to withstand scientific scrutiny internationally, with public health authorities in Sweden, Finland, and most recently England doing a U-turn on pediatric gender transitions”).
10 AHRQ, p. 2.
11 JM de Blok et al., “Mortality Trends Over Five Decades In Adult Transgender People Receiving Hormone Treatment: A Report From the Amsterdam Cohort of Gender Dysphoria,” Lancet Diabetes Endocrinol., 2021 Oct., Vol. 9(10),pp. 663-670; see Dhejne et al., “Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden,” PLoS ONE, 6(2): e16885, 2011, p. 7 (finding “substantially higher rates” of overall mortality, including from cardiovascular disease and suicide, and psychiatric hospitalizations in sex-reassigned transsexual individuals); Asscheman, “A Long-Term Follow-Up Study of Mortality in Transsexuals Receiving Treatment with Cross-Sex Hormones,” Euro. J. of Endocrinol., 2011, 164, 635-642, pp. 639-40 (finding 51% increased mortality rate in male-to-female transsexual subjects despite having treated with cross-sex hormones, as compared to the general male population, including due to suicide); Jackson et al., “Analysis of Mortality Among Transgender and Gender Diverse Adults in England,” JAMA Network Open, 2023, Vol. 6(1), e2253687, p. 7 (finding transgender and gender diverse individuals have “increased risk of overall mortality, ranging from 34% to 75%”).
12 Ristori et al., “Gender Dysphoria in Childhood,” Intern. Rev. of Psychiatry, 2016, p. 3; see also Hruz et al., p. 19 (observing “most children who identify as the opposite sex will not persist in these feelings and will eventually come to identify as their biological sex”); Hembree et al., Endocrine Treatment of GenderDysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline, J. Clin. Endocrinol. Metab., November 2017, p. 3879 (noting “the large majority (about 85%) of prepubertal children with a childhood diagnosis did not remain GD/gender incongruent in adolescence”).
13 Schwartz, “Clinical and Ethical Considerations in the Treatment of Gender Dysphoric Children and Adolescents: When Doing Less is Helping More,” J. of Infant, Child, and Adolescent Psychotherapy, Vol. 20, No. 4, 439-449, 2021, p. 442.
14 Socialstyrelsen NBHW, p. 3.
15 Haupt et al., “Antiandrogen or estradiol treatment or both during hormone therapy in transitioning transgender women (Review),” Cochrane Library: Cochrane Database of Systematic Reviews, 2020, Issue 11, Art. No. CD013138, pp. 2, 4.
16 Littman, “Parent Reports of Adolescent and Young Adults Perceived to Show Signs of a Rapid Onset of Gender Dysphoria,” PLoS ONE, 13(8), 2018, pp. 33-34.
17 Diaz et al., “Rapid Onset Gender Dysphoria: Parent Reports on 1655 Possible Cases,” Archives of Sexual Behavior, 2023, p. 11.
18 Id.
19 FDA, “Risk of pseudotumor cerebri added to labeling for gonadotropin-releasing hormone agonists,” American Academy of Pediatrics, AAP News, July 1, 2022.
20 Biggs, p. 3 (quoting researcher who acknowledged “we really don’t know what suppressing puberty does to your brain development”); Hruz et al., pp. 10, 24 (noting study suggesting sex hormones may contribute to organizational effects in the brain during puberty, and noting suspicion puberty suppression may have negative consequences for neurological development and spatial memory); “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,” p. 7 (“It is not known how the hormonal suppression of puberty affects young people’s judgement and decision-making.”); Cass, “Independent Review of Gender Identity Services for Children and Young People: Interim Report,” Feb. 2022, p. 38 (“It is known that adolescence is a period of significant changes in brain structure, function, and connectivity” including development of frontal lobe functions which control “decision making, emotional regulation, judgement and planning ability”).
21 Cass, p. 38 (noting “96.5% and 98%” rates); see also Kelleher, “The Dutch Model Is Falling Apart,” Genspect, Jan. 2, 2023, https://genspect.org/the-dutch-model-is-falling-apart/ (quoting Dutch journalists that “‘puberty blockers are not a “pause button” but a self-fulfilling prophecy. Almost all treated children move from puberty blockers to cross-sex hormones at 16. In practice, puberty blockers do not appear to be a pause button for reflection, but the start button for transition.’”).
22 Baker et al., p. 12; see also Hruz et al., p. 6 (“the evidence for the safety and efficacy of puberty suppression is thin”).
23 Krishna et al., “Use of Gonadotropin-Releasing Hormone Analogs in Children: Update by an International Consortium,” Horm. Res. Paediatr., 91:357-372, 2019, p. 365; Coleman et al., SOC 8, pp. S256-S257 (WPATH criteria for both puberty blockers and hormone therapy for adolescents include provision that adolescent be informed on “potential loss of fertility and the available options to preserve fertility”); see also Hruz et al., pp. 24-25 (noting infertility to be major side effect of puberty suppression—cross-sex hormone—surgical reassignment treatment course).
24 “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,” p. 7 (noting possibility hormone therapy may work to consolidate a gender identity that would have otherwise changed in some adolescents, and recommending no decisions be made that could permanently alter a still-maturing minor’s mental and physical development); Hruz et al., pp. 22-23 (“one would expect that the development of natural sex characteristics might contribute to the natural consolidation of one’s gender identity,” and noting a possibility puberty suppression could interfere in that process).
25 Rafferty, Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents, American Academy of Pediatrics, Vol. 142, no. 4, Oct. 2018, p. 5 (noting research on long-term risks of puberty suppression on bone metabolism is limited with varied results); Biggs, p. 3 (quoting research proposal which acknowledged “[i]t is not clear what the long term effects of early suppression may be on bone development, height”); Hruz et al., p. 18 (noting concern about bone-mineral density for children and adolescents treated with puberty suppression); Coleman et al., SOC 7, p. 20 (WPATH acknowledging concerns about negative physical side effects of puberty suppression on bone development and height).
26 Hruz et al., p. 15 (noting a “lack of understanding of the causes of gender dysphoria in children or adults” and noting puberty suppression cannot, therefore, directly address it); Baker et al., p. 13 (admitting “[m]ore research is needed” to explore the relationship between hormone therapy and quality of life, suicide, and other psychological outcomes “especially among adolescents”); Coleman et al., SOC 7, p. 20 (WPATH admitting the “long-term effects” of puberty suppression can only be determined when the earliest-treated patients “reach the appropriate age”); Gauffin et al., p. 1 (Swedish SBU published an overview of the knowledge base which showed “a lack of evidence” for the “long-term consequences” of puberty suppression and cross-sex hormones); NICE, “Evidence Review: Gender-Affirming Hormones for Children and Adolescents with Gender Dysphoria,” National Inst. For Health and Care Excellence, 2021, p. 14 (UK health agency concluding “[a]ny potential benefits of gender-affirming hormones must be weighed against the largely unknown long-term safety profile of these treatments in children and adolescents with gender dysphoria”).
27 Singh et al., “A Follow-Up Study of Boys With Gender Identity Disorder,” Front. Psychiatry, 12:632784, March 2021, p. 12 (finding desistance from gender dysphoria to be “by far the more common outcome”); Cantor, “Transgender and Gender Diverse Children and Adolescents: Fact-Checking of AAP Policy,” J. of Sex & Marital Therapy, Taylor & Francis Group, LLC, 2019, p. 1 (observing follow-up studies of gender diverse children, “without exception,” found that over puberty the majority cease to want to transition); Hembree et al., p. 3876 (noting “a minority” of prepubertal children with gender incongruence persist into adolescence).
28 Hembree et al., p. 3879.
29 Coleman et al., SOC 7, p. 12.
30 Hruz et al., pp. 22-26 (noting “little sense” in describing puberty suppression as reversible, laying out potentially irreversible effects on both physical and mental health); Coleman et al., SOC 7, p. 35 (WPATH acknowledging hormone therapy “may lead to irreversible physical changes”); see also Kelleher (quoting Dutch journalists that “‘more is becoming known about the long-term side effects of puberty blockers. They interfere with physical sexual development, hinder the development of the bones, can cause anorgasmia and infertility and interfere with the ability to make rational decisions.’”); “Medicine and Gender Transidentity in Children and Adolescents” (French National Academy of Medicine noting side effects of puberty suppressants and hormone therapy include “impact on growth, bone fragility, risk of sterility, emotional and intellectual consequences and, for girls, symptoms reminiscent of menopause”).
