United States: the “HHS Report” on Gender Dysphoria in Minors – Magali Pignard
- La Petite Sirène
- Jul 22
- 8 min read
United States – “HHS Report” on Gender Dysphoria in Minors – Magali Pignard, July 6, 2025
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Based on a review of international evidence, this U.S. government report raises concerns about the weak data supporting medical treatments for minors with gender dysphoria.
For several years, the use of hormonal and surgical treatments for minors questioning their gender has been the subject of intense scientific and ethical debate. A new U.S. government report reinforces concerns expressed by several European countries.
Published on May 1, 2025, by the U.S. Department of Health and Human Services (HHS), this document of over 400 pages—"Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices"—is to date the most comprehensive governmental analysis ever conducted on medical transitions in minors.
"This is not a clinical recommendation nor a public policy document. Rather, it aims to provide the most accurate and up-to-date information available regarding the state of the evidence." (p. 1)
Why this report? Who commissioned it?
The report was commissioned by a presidential executive order signed by Donald Trump in January 2025. It instructed the Department of Health to reexamine best practices regarding children with gender dysphoria.
How is the HHS report structured?
The report includes an Executive Summary (pp. 12 to 16) and is organized into five major parts:
Historical Context
Systematic Review of the Evidence
Analysis of Clinical Practices
Medical Ethics
Role of Psychotherapy
What the report reveals:
On the certainty of evidence for endocrine treatments:
Part II of the HHS report (pages 51 to 156) is devoted to a methodologically rigorous evaluation of the scientific knowledge available on medical interventions proposed for minors with gender dysphoria.
Falling within the scope of evidence-based medicine, this section relies on a synthesis of major international systematic reviews, including those used by health authorities in countries like Sweden, Finland, and the United Kingdom. This approach, described as an "umbrella review," provides an overall picture of the level of certainty associated with the documented benefits and risks in the literature.
"The umbrella review concluded that the overall level of confidence in the data on the effects of interventions—on psychological outcomes, quality of life, regret, or long-term health—is very low. This means that the reported beneficial effects in the literature are likely to differ substantially from the actual effects." (Executive Summary, p. 13)
The report also highlights that available data on adverse effects is limited, but that this scarcity should be interpreted with caution. The lack of risk detection could be explained by several factors:
the relatively recent adoption of the large-scale medical/surgical model;
the frequent absence of systematic longitudinal follow-up in clinical studies;
a publication bias favoring positive results.
"Evidence regarding the harmful effects of pediatric medical transition is also limited in systematic reviews, but this finding should be interpreted with caution." (p. 13)
The report also details, in several sections (notably pages 83 to 90 and 240 to 258), the risks associated with these medical interventions, drawing from systematic review data, pharmacovigilance systems (like FAERS), and established pathophysiological knowledge.
Regarding puberty blockers, the identified risks include decreased bone mineral density, effects on neurocognitive development, and long-term disruption of reproductive maturation (hypogonadism). The report notes that their use in this context is off-label and that they almost systematically lead to subsequent initiation of hormone therapy.
For cross-sex hormones, the risks include cardiovascular disorders (thrombosis, stroke), metabolic dysregulation (diabetes, dyslipidemia), psychiatric effects (depression, aggression, mood disorders), and a possible alteration of sexual and reproductive functions, often irreversible.
The U.S. pharmacovigilance system (FAERS) records a high rate of serious adverse effects, particularly among teenage girls on testosterone. The report specifically notes two deaths, several hospitalizations, and cases of suicidal ideation.
These findings reinforce the methodological warning of the report: the absence of robust data should not be interpreted as evidence of safety, and the precautionary principle should guide clinical practice.
"Systematic reviews are generally more sensitive to detecting benefits than harms. The absence of risk data in published studies cannot be interpreted as proof that those risks do not exist." (p. 14)
On the WPATH (World Professional Association for Transgender Health)
Part III of the report (pages 157 to 178) is devoted to a critical analysis of the clinical guidelines that govern the medical care of gender dysphoria in minors, particularly the Standards of Care, version 8 (SOC-8), published by WPATH. These recommendations are among the most influential internationally, including in France.
The report draws on an independent systematic review (Taylor et al., 2024), conducted for the British Cass Review, which evaluated 21 international guidelines using the AGREE II tool. This review concluded that the WPATH and Endocrine Society recommendations "lack rigor in development and transparency" and are not suitable for clinical practice.
Beyond these methodological shortcomings, the HHS report highlights several serious failings in the development of SOC-8:
The deliberate suppression of systematic reviews commissioned from Johns Hopkins University but deemed unfavorable to the affirmative model (see the full analysis on the suppression of these reviews in this post);
Violations of conflict-of-interest management rules, as authors failed to declare or account for close ties to commercial or activist interests;
The politically pressured removal of initially planned minimum ages for hormonal and surgical treatments (except phalloplasty), as reported by The New York Times on June 25, 2024.
The report criticizes an affirmative model in which psychiatric evaluations are sometimes reduced to a single two-hour session, with decisions primarily guided by the adolescent's stated "embodiment goals."
Finally, the report emphasizes that the apparent professional consensus in favor of early medical transitions is in reality supported by a small number of specialized committees close to WPATH and does not necessarily reflect the opinion of the wider healthcare community. Documented signs of institutional pressure exist, aimed at silencing dissenting voices, including whistleblowing clinicians and individuals who have detransitioned.
On Ethical Considerations
Part IV of the report (pages 213 to 234) addresses the ethical foundations of medical transition treatments in minors. It provides an in-depth analysis of the four major principles of bioethics (autonomy, beneficence, non-maleficence, and justice) and concludes that current practices raise serious ethical compliance concerns, especially in the pediatric context.
1. Autonomy: A Misapplied Principle (pp. 214–216)
The report notes that the patient's right to refuse medical treatment is morally and legally established, but this does not imply a symmetrical right to demand treatment the physician deems non-beneficial.
"Respect for patient autonomy does not justify subjecting patients to medical interventions that carry unnecessary risks or are otherwise non-beneficial, even when the patients prefer, request, or demand them." (p. 215)
2. Benefit/Risk Ratio: The Duty of Precaution (pp. 217–222)
The HHS emphasizes that the benefits of these treatments are highly uncertain, while some risks are probable, particularly infertility, bone loss, and cognitive or metabolic effects.
"The unfavorable benefit/risk profile sets pediatric medical transition apart from many other off-label uses of medications or medical devices." (p. 222)
3. Regret: An Irrelevant Criterion (pp. 231–233)
The report asserts that neither expressed regret nor the absence of it alone is a sufficient indicator to justify an intervention.
"Regret alone (just like satisfaction alone) is not a valid indicator for determining whether an intervention is medically justified." (p. 232)
An example is given: a man might not regret an operation he nevertheless misunderstood or should never have been subjected to.
"The fact that this man does not regret the procedure does not mean that his decision was wise or that the surgeon was justified in offering it to him." (p. 233)
4. Research: Ethical Feasibility Disputed (pp. 233–234)
The report notes that some researchers claim that conducting randomized controlled trials (RCTs) on blockers or hormones would be ethically impossible. It refutes this position:
"This claim is unfounded, as it distorts the current state of scientific knowledge." (p. 234)
The report also criticizes the idea that there is already a medical consensus on the effectiveness of the treatments, which would make comparative studies unnecessary or even unethical. On the contrary, it argues that, in the absence of solid data, one cannot rely solely on beliefs or ideological preferences: rigorous research remains necessary to determine whether these treatments are truly beneficial.
On Psychotherapy: An Underexplored and Stigmatized Alternative
The final part of the report (pages 238 to 274) focuses on this topic.
1. A Neglected Approach in a Broader Crisis Context
The report begins by placing the rise in medical transition requests within the context of a broader adolescent mental health crisis. It observes that the relationship between this crisis and the increase in gender dysphoria cases remains uncertain and scientifically controversial.
"The rise in gender dysphoria among youth and the corresponding demand for medical interventions have occurred within the broader context of a mental health crisis affecting adolescents. The relationship between these two phenomena remains a matter of scientific debate." (Executive Summary, p. 16)
2. No Evidence That Medical Transition Reduces Suicide
The report highlights a central point: suicidal ideation is strongly correlated with other psychiatric disorders common among youth with gender dysphoria (depression, anxiety, eating disorders, autism). No demonstrated link exists between dysphoria itself and suicide, nor is there evidence that medical transition reduces suicide rates.
"No independent association between gender dysphoria and suicidality was found, and there is no evidence that pediatric medical transition reduces the incidence of suicide, which fortunately remains very low." (Executive Summary; confirmed pp. 252–254)
3. Psychotherapy Understudied Due to Confusion with "Conversion Therapy"
The report notes a lack of research on psychotherapeutic interventions for gender dysphoria. This is partly due to the stigmatization of any non-affirmative approach, often wrongly equated with "conversion therapy."
"There is a shortage of research on psychotherapeutic approaches for managing gender dysphoria in children and adolescents. This is partly due to the mischaracterization of such approaches as 'conversion therapies.'" (Executive Summary)
4. A Recognized Framework for Comorbidities, But Not for Dysphoria Itself
Approaches such as CBT (cognitive-behavioral therapy), family therapy, psychodynamic therapy, and "transdiagnostic" interventions are well-validated for co-occurring psychiatric disorders — but scarcely studied for dysphoria itself.
"Although several studies suggest that psychotherapy may effectively resolve dysphoria non-invasively, the quality of the evidence is very low. (...) Systematic reviews have found no evidence of harm related to psychotherapy in this context." (pp. 252–253)
5. An Urgent Need for Clinical Development and Research
Finally, the report calls for the creation of explicit clinical pathways for non-medical approaches and for defining a rigorous research strategy to evaluate their effectiveness:
"There is a need to develop an explicit clinical pathway for non-medical interventions, as well as a research strategy to evaluate their effectiveness." (p. 251; Cass Review 2024, 11.43)
Limitations of the HHS Report
Although the HHS report (2025) adopts a rigorous and methodical approach, several limitations must be noted to clarify its scope.
The report deliberately replaces standard terms such as "gender-affirming care" with "pediatric medical transition," considering that much of the vocabulary used in transgender medicine is ideologically and scientifically unfounded. This rejection of certain terms ("trans child," "gender assigned at birth," etc.) is consistent with a desire for epistemological neutrality, but may also be seen as a controversial editorial choice, breaking from the language typically used by healthcare professionals. Chapter 2 of the report describes this semantic shift as both a scientific and ethical-political issue.
"In this context, the understandable desire to avoid exclusionary or pathologizing language, combined with deeply held convictions in the field, has led to the adoption of a vocabulary and mode of communication that are not scientifically grounded, that presuppose answers to ethical controversies, and that are, in other respects, misleading." (p. 29)
The report’s authors are not named, which has drawn criticism, notably in the American press. According to Jesse Singal (The Dispatch, May 1, 2025), their names were deliberately withheld “in order to help preserve the integrity of the process,” as stated by an HHS spokesperson. Nevertheless, several observers believe this lack of transparency may weaken the report’s credibility among the public or professionals seeking to assess potential bias.
The political context of its commissioning — a presidential decree by Donald Trump titled Protecting Children from Chemical and Surgical Mutilation — has contributed to mistrust from many medical and activist circles. However, as The Economist noted (May 5, 2025):
"What the team mandated by the department produced is, against all odds, rigorous."
The report should therefore be judged on the substance of its analyses and not solely on its political origin.
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