FIRST ON THE DAILY SIGNAL—Psychiatrists, endocrinologists, neurologists, and other doctors testified in support of a Florida health agency’s rule preventing Medicaid from funding various forms of “gender-affirming care,” such as “puberty-blockers,” cross-sex hormones and transgender surgeries.
“Patients suffering from gender dysphoria or related issues have a right to be protected from experimental, potentially harmful treatments lacking reliable, valid, peer-reviewed, published, long-term scientific evidence of safety and effectiveness,” Dr. Paul Hruz, an endocrinology researcher and clinician at Washington University School of Medicine, wrote in a sworn affidavit provided exclusively to The Daily Signal. (Endocrinologists treat the endocrine system, which uses hormones to control metabolism, reproduction, growth and more.)
Hruz joined with other doctors in testifying in support of Florida’s Agency for Health Care Administration, which finalized a rule in August 2022, declaring that Medicaid would not cover “puberty blockers,” cross-sex hormones, “sex-reassignment” surgeries, or other procedures that alter primary or secondary sex characteristics.
LGBT and health activist groups led by Lambda Legal represent four young people who identify as transgender and who filed a lawsuit in September aiming to block the rule. As part of their lawsuit, the LGBT groups asked the court to temporarily block the rule while it considers the full case. In denying that temporary injunction, the court ruled in October that the case centers on whether Florida’s determination that the transgender interventions are “experimental” is “reasonable.”
The AHCA filed a motion for summary judgment on Friday, urging the court to close the case and make a final judgment supporting the rule. In that motion, exclusively provided to The Daily Signal, AHCA referenced the testimony of many doctors warning about “gender-affirming care.”
Hruz and other doctors argue that the medical interventions often described as “gender-affirming care” are experimental and that the organizations that present standards of care supporting them—the World Professional Association for Transgender Health and the Endocrine Society—represent more a political and advocacy effort than an objective analysis supporting these alleged treatments.
AHCA asked WPATH and the Endocrine Society to hand over the documents they used to craft their treatment protocols, but the organizations at first declined, then handed over a limited selection of documents that AHCA found insufficient. AHCA calls “the continued reluctance” of these organizations “significant, especially when [the LGBT groups] and their experts rely extensively on the WPATH standards of care and the Endocrine Society’s guidelines.”
Dr. Stephen B. Levine, a psychiatrist and early proponent of transgender medical interventions, joined and briefly helped lead the Harry Benjamin International Gender Dysphoria Association, which later became WPATH. A member from 1974 to 2001, he served as the chairman of the eight-person International Standards of Care Committee that issued the fifth version of the standards of care.
In his affidavit, Levine notes that he resigned his membership in 2002 due to “my regretful conclusion that the organization and its recommendations had become dominated by politics and ideology, rather than by scientific process, as it was years earlier.” He condemns the WPATH standards of care as “not an impartial or evidence-based document.”
Levine notes that “WPATH explicitly views itself as not merely a scientific organization, but also as an advocacy organization.” He notes that WPATH welcomes non-doctors into its membership, so long as they identify as transgender. “Skepticism as to the benefits of [‘sex-reassignment surgery’] to patients, and strong alternate views, are not well-tolerated in discussions within the organization or their educational outreach programs,” he said.
While “WPATH claims to speak for the medical profession,” it “represents a self-selected subset of the profession along with its many non-professional members” and it “does not welcome skepticism and therefore deviates from the philosophical core of medical science,” Levine writes.
The psychiatrist explains that “there is no consensus or agreed ‘standard of care’ concerning therapeutic approaches to child or adolescent gender dysphoria.” He notes that gender identity “is not biologically based” and “empirically not fixed for many individuals.” He also warns that social transition “is a powerful psychotherapeutic intervention that radically changes outcomes” and makes it far less likely that young children will “desist” from a transgender identity.
Levine explicitly calls transition and affirmation “experimental therapies that have not been shown to improve mental or physical health outcomes by young adulthood,” and warns that these therapies “do not decrease, and may increase, the risk of suicide.”
He further warns that hormonal interventions “are experimental procedures that have not been proven safe.” So-called puberty blockers and cross-sex hormones can have negative effects on fertility, bone density, brain development, and psychosocial wellbeing.
Levine concludes that support for childhood medical interventions “is currently being reinforced by an echo chamber of approval from other like-minded, child-oriented professionals who do not sufficiently consider the known negative medical and psychiatric outcomes of trans adults.”
“Rather than recommend social transition in grade school, the [mental health professional] must focus attention on the child’s underlying internal and familial issues,” he concludes.
Endocrinologists Hruz, Michael Laidlaw, and Quentin Van Meter also testify to the problems with “puberty blockers” and cross-sex hormones. Hruz warns that after “an extended period of pubertal suppression,” patients can’t “turn back the clock” and “reverse changes in the normal coordinated pattern of adolescent psychological development and puberty.”
Hruz notes that “there are no long-term, peer-reviewed published, reliable and valid research studies” documenting the percentage of patients helped or harmed by transgender medical interventions. He also notes that attempts to block puberty followed by cross-sex hormones not only impact fertility, but also pose risks such as low bone density, “disfiguring acne, high blood pressure, weight gain, abnormal glucose tolerance, breast cancer, liver disease, thrombosis, and cardiovascular disease.”
In the absence of transgender interventions, children often grow to reject a transgender identity, he observes.
For these reasons, Hruz concludes that “administering hormones to a child whose gender dysphoria is highly likely to resolve is risky, unscientific, and unethical.”
Dr. Patrick W. Lappert, a plastic surgeon, writes in his affidavit that “it is axiomatic in plastic surgery that we are to avoid a predictable sacrificing of function in the pursuit of cosmetic improvement.” Yet the WPATH standards of care present two surgeries—mastectomy and genital surgery—that are entirely cosmetic as medically necessary.
Lappert notes that the removal of healthy breasts—which WPATH recommends for masculine-identifying girls as young as 15—”includes the 100% likelihood of a massive functional loss,” and therefore “must be considered unsupportable as a matter of public policy.”
He also notes that genital surgeries seek “to create counterfeit structures that never could have existed in the patient, except as an artifact of surgery” and which “are 100% certain to produce grave functional losses.” He concludes that these interventions “must not be supported as a matter of public policy, and never be paid for using public funds.”
Dr. Sophie Scott, a neuroscientist from the United Kingdom, explains that the effects of certain chemicals on the human brain aren’t well known, and that current science does not support “puberty blockers” for adolescents.
“As puberty is associated with very marked changes in the structure of the brain … the use of puberty blockers may have serious consequences for the development of the human brain,” Scott warns. Studies in sheep and young girls suggest that these drugs impact the size of the amygdala. Male sheep treated with the drugs showed “more risk-taking behaviors,” while treated female sheep “showed higher levels of anxiety and greater avoidance behavior.” Girls treated with the drug also showed “significant greater emotional reactivity” and “lower heart rates.” Girls also scored lower on IQ tests after taking the drugs.
“I am very concerned that the current treatment regime is exposing young people to significant risk of harm,” Scott writes.
Both the doctors and the AHCA repeatedly note that foreign countries are finding support for these medical interventions “insufficient” and are recommending a “watchful waiting” approach for minors. Australia, Finland, France, New Zealand, Norway, Sweden, and the United Kingdom have recently moved in that direction.
Even the U.S. federal government declined to endorse the experimental treatments until recently. The AHCA motion for summary judgment cited the Centers for Medicare and Medicaid Services, which in 2016 declined to make a determination on “gender reassignment surgery for Medicaid beneficiaries with gender dysphoria because the clinical evidence is inconclusive for the Medicare population.” That document acknowledged the lack of “enough high-quality evidence” to determine the benefits of surgery. The centers have not issued another memorandum on the issue.
In 2020, the Department of Health and Human Services declined to “take a definitive view on any of the medical questions raised” about treatments for gender dysphoria due to the “lack of high-quality evidence” supporting them and the reliance on an “advocacy group (WPATH) rather than on independent scientific fact-finding.” In March 2022, however, the department under President Joe Biden—in contrast to its finding under former President Donald Trump—released a “notice and guidance on care” firmly endorsing transgender interventions with “little scientific support” included, the AHCA brief notes.
The AHCA motion for summary judgment also cites Dr. Armand Antommaria, a professor at Cincinnati Children’s Hospital Medical Center, who serves as an expert witness for the LGBT groups. Antommaria concedes that of the 28 recommendations in the Endocrine Society’s guidelines, “three are backed by moderate-quality evidence, fourteen are backed by low-quality evidence, five are backed by very low-quality evidence, and six are backed by no evidence at all.”
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