July 15, 2024

Dear Secretary Beccera and Assistant Secretary Dr. Levine,

We strongly urge you to revise the HHS guidance on gender-affirming care to ensure that public health policies are based on quality scientific evidence and are not doing more harm than good for children with gender dysphoria.

HHS guidelines “unequivocally [state] that gender affirming care for minors, when medically appropriate and necessary, improves their physical and mental health. Attempts to restrict, challenge, or falsely characterize this potentially lifesaving care as abuse is dangerous.” 

These guidelines are based on the Moving Beyond Change Efforts: Evidence and Action to Support and Affirm LGBTQI+ Youth report published in March 2023. This report was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA) by Leed Management Consulting, Inc. and written by an unbalanced panel of experts. 

However, since 2020, public health and top medical officials in England, Denmark, Finland, Norway, and the Netherlands have changed their guidelines and policies for the treatment of children with gender dysphoria. These nations have restrictions on the use of GnRH agonists and sex hormones in children and adolescents with gender dysphoria based on the growing body of evidence demonstrating that these treatments do not benefit mental health or alleviate symptoms of gender dysphoria in children.

The data from several systematic reviews published in peer-reviewed journals, (England's Final Cass Report is the most recent and comprehensive), demonstrate that:

• Social transition has neither positive nor negative effects on psychological distress or mental health in children or adolescents with gender dysphoria but may serve as the gateway to medical transition.

• Without social and medical transition, 78% of children and adolescents diagnosed with gender dysphoria will proceed through normal development and will NOT be transgender adults.

• Children with gender dysphoria have the same rate of suicide as children with other serious mental health disorders, and the rate of death by suicide at the world's largest gender clinic was 0.03% in 10 years.

• There is no high-quality evidence that social transition, puberty blockers, or sex hormones reverse the symptoms of gender dysphoria or mitigate suicide risk.

Dr. Levine, as Assistant Health Secretary, you play a vital role in setting the tone for guidelines and policies that support children's health. A 2022 article in the Washington Examiner revealed a 2017 email correspondence between you and the co-founder of Children’s Hospital of Philadelphia's Gender and Sexuality Development Clinic in which you inquired, "I know that we had discussed at US PATH the possibility of gender confirmation surgery for young people under 18 years of age. This could include top surgery for trans young men and top and bottom surgery for trans young women. Is there any literature to support this protocol?" Dr. Nadia Dowshen replied: "Hi Rachel, I'm not aware of existing literature, but it is certainly happening. I think we've had more than 10 patients who have had chest surgery under 18 (as young as 15) and 1 bottom surgery (17)." 

Despite having this knowledge, you have lobbied against legislation and policies that propose restrictions on medical and surgical transition. The New York Times recently reported that your office communicated with the World Professional Association for Transgender Health (WPATH) and advised them to remove age restrictions for medical and surgical treatments in developing their Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 guidelines released in 2022.

As HHS Assistant Secretary, you can access all of the scientific evidence leading European nations use to drive their policies. Your credentials as a Pediatrician, Adolescent Psychiatrist, and Fellow of the American Academy of Pediatrics (AAP) give you the qualifications to weigh the evidence and influence the policies of medical organizations, such as the WPATH, AAP, American Endocrine Society, and the American Association for Child and Adolescent Psychiatry (AACAP).

Instead, you promote the practice of schools imposing unproven psychological interventions (like social transition) on children without the input, knowledge, or consent of their parents. What's more, these psychological interventions are often enacted by educators and counselors who do not have the appropriate knowledge, training, or information to intervene in a student’s mental health care. Furthermore, the Cass Report and AACAP have raised evidence of the potential harm of social transition.

Parents, educators, and other American citizens who are involved in the health and development of children are often unaware of these policies, may be confused about much of gender identity terminology, and have concerns about how American health and school policy is different from that in European nations. School policies are guided by the US Departments of Education and Health and Human Services and by advocacy groups intent on pushing the ideology that children can be born in the wrong body. These policies drive school curricula, discrimination, and behavioral policies.

HHS guidelines should reflect the most up-to-date scientific evidence and recommendations for treating children with gender dysphoria. These guidelines should support the whole health of children with gender dysphoria and their peers but should not encourage a medical pathway or conflict with or supersede parental guidance.

We Propose the Following Actions by HHS:

• Commission an American review of the scientific evidence, treatment practices, and outcomes of children with gender dysphoria. 

• Revise HHS recommendations to reflect the most comprehensive review of available scientific evidence. 

• Guide the nation’s scientific and medical organizations to conduct rigorous scientific studies, provide medical guidance that values ethical norms such as benevolence and informed consent, and have transparent debate on the evidence.

• Encourage the nation to have respectful conversations about this topic, now affecting more than 300,000 US youth. To facilitate this, Restore Childhood, a nonprofit organization dedicated to restoring the whole health of children, created a toolkit that compiles the most recent scientific data on gender and schools and provides tools that parents, educators, and concerned citizens can use to have this Urgent Conversation.

Children in distress from gender dysphoria deserve the very best care available and should be treated with compassion and dignity. However, proceeding with treatments that provide no proven benefit, cause iatrogenic harm, and are more ideological than scientific, violates ethical principles that have made the American healthcare system a model for the world. Our medical and scientific communities are failing children, their families, and the nation by continuing down this path. 

It is your duty to demand and lead these changes to protect our children from harm.

Signed,