Health officials in the Biden administration pushed an international panel of medical experts to remove age limits for teenage procedures from guidelines for care of transgender minors, according to newly unsealed court documents.
Minimum ages, officials fear, could fuel growing political opposition to such treatments.
Email excerpts from members of the World Professional Association for Transgender Health recount how staff at Adm. Rachel Levine, an assistant secretary for health at the Department of Health and Human Services and herself a transgender woman, urged them to remove the recommended limits from the group’s guidelines, and apparently succeeded.
Whether and when teenagers should be allowed to undergo transgender treatments and surgeries has become a heated debate in the political world. Opponents say teenagers are too young to make such decisions, but advocates, including a number of medical experts, argue that youth with gender dysphoria face depression and worsening anxiety if their issues are not addressed.
In the United States, setting age limits has been controversial from the start.
The draft guidelines, released in late 2021, recommended lowering the minimum age to 14 for hormone treatments, 15 for mastectomies, 16 for breast augmentation or facial surgery, and 17 for genital surgery or hysterectomy.
The proposed age limits were dropped in the final guidelines outlining standards of care, prompting concerns within the international team and with outside experts about why the age recommendations had disappeared.
Excerpts of emails released this week shed light on possible reasons for those changes in guidelines and highlight Admiral Levine’s role as a leading figure on transgender issues in the Biden administration. The excerpts are legal filings in a federal lawsuit challenging Alabama’s ban on gender-affirming care.
A quote from an anonymous member of the WPATH guideline development team recalls a conversation with Sarah Boateng, then serving as Admiral Levin’s chief of staff: “She’s confident, based on the rhetoric she’s hearing in DC and what we’ve already seen , that these specific age listings, under 18, will lead to disastrous transgender care legislation. He wonders if the specific ages can be removed.”
Another email said Admiral Levine was “very concerned that age (especially for surgery) will affect access to care for transgender youth and perhaps adults. Apparently the situation in the US is dire and she and the Biden administration are worried that having ages on the document will make things worse. He asked us to remove them.”
The excerpts were filed by James Cantor, a psychologist and longtime critic of sex therapy for minors, who used them as evidence that the international advisory group, referred to as WPATH, was making decisions based on politics, not science, to develop the Guidelines.
The emails were part of a report he submitted in support of Alabama’s ban on the medical treatment of transgender minors. No emails from Admiral Levine’s staff have been released. The plaintiffs are seeking to bar Dr. Cantor from testifying in the case, claiming he lacks experience and his opinions are irrelevant.
Admiral Levine and the Department of Health and Human Services did not respond to requests for comment, citing pending litigation.
Dr. Cantor said he filed the petition to reveal the contents of the group’s internal emails obtained by subpoena in the case, most of which remain sealed due to a protective order. “What’s being said in public is completely different from WPATH’s private discussions,” he said.
Dr. Marci Bowers, a gynecologist and reconstructive surgeon and president of WPATH, rejected that claim. “It wasn’t political, the politics were already apparent,” said Dr. Bowers, who is a trans woman. “WPATH does not consider politics when making a decision.”
In other emails released this week, some WPATH members expressed their disagreement with the proposed changes. “If our concern is about legislation (which I don’t think it should be – we should base it on science and expert consensus if we’re ethical) wouldn’t it be useful to include ages?” one member wrote. “I need someone to explain to me how removing the ages will help fight the conservative anti-trans agenda.”
The international panel of experts finally removed the minimum age limits in the eighth edition of the standards of care, released in September 2022. The guidelines reflected the first update in a decade and were the first edition of the standards to include a dedicated chapter on the medical care of transgender teenagers.
The field of adolescent gender transition care is relatively new, and evidence on long-term outcomes is scarce. Most transgender teenagers who receive medical interventions in the United States are prescribed puberty-blocking drugs or hormones, not surgery.
But as the number of young people seeking such treatments has increased, prominent clinicians around the world have disagreed on issues such as the ideal timing and criteria for medical interventions. Several countries in Europe, including Sweden and Britain, recently put new restrictions on sex drugs for teenagers after reviews of the scientific evidence. In these countries’ health systems, surgeries are only available to patients 18 years of age or older.
The email documents were released by the US District Court for the Middle District of Alabama in a challenge to Alabama’s ban by civil rights groups including the National Center for Lesbian Rights and the Southern Poverty Law Center on behalf of five transgender teenagers and their families.
Transgender rights groups have turned to the courts to block laws like Alabama’s passed in more than 20 Republican-controlled states by 2021, but the courts have been divided on their rulings.
On Monday, the Supreme Court announced it will hear a challenge to Tennessee’s ban on youth sex medicine, which makes it a felony for doctors to provide any sex-related treatment to minors, including puberty blockers, hormones and surgery. The petition, filed by the Department of Justice, cited WPATH’s guidelines among the key “evidence-based practice guidelines for the treatment of gender dysphoria.”
Additional emails cited in the new court filings suggest that the American Academy of Pediatrics also warned WPATH that it would not endorse the group’s recommendations if the guidelines set the new minimum ages.
In a statement Tuesday, Mark Del Monte, chief executive of the American Academy of Pediatrics, pointed out that the medical group, which represents 67,000 US pediatricians, had not endorsed the international guidelines because it already had its own.
He said the academy sought to change the age limits in the guidelines because the group’s policies did not recommend age-based restrictions for surgeries.
Last summer, the pediatric academy reaffirmed its own guidelines, issued in 2018, but said it commissioned an external review of the evidence for the first time.
The numbers for all sex-related medical interventions for adolescents are steadily increasing as more young people seek such care. A Reuters analysis of insurance data estimated that 4,200 American teenagers started estrogen or testosterone therapy in 2021, more than double the number four years earlier. Surgical procedures are rarer and the vast majority are mastectomies. or major surgeries. In 2021, Reuters estimated that 282 teenagers had top surgery paid for by insurance.
Sex-reassignment surgery for minors has been a focus for some politicians. Gov. Ron DeSantis, Republican of Florida, has argued that surgeons should be sued for “disfiguring” children. In Texas, where parents of transgender children have been investigated for child abuse, Gov. Greg Abbott, a Republican, has called genital surgeries on teenagers “genital mutilation.”
WPATH’s final guidelines state that distress about breast development in particular has been associated in transgender adolescents with higher rates of depression, anxiety, and distress.
“While the long-term effects of gender confirmation treatments initiated in adolescence are not fully known, the potential negative health consequences of delaying treatment should also be considered,” the guidelines state.
“Gender-affirming surgery is highly valued by those who need these services — in many cases, life-saving,” Dr. Bowers said.
