Biden administration health officials have pressured an international group of medical experts to remove an age limit for puberty surgery from guidelines for the care of transgender minors, according to newly unsealed court documents.
Officials worry that an age restriction could add to growing political opposition to such treatments.
Excerpts of emails from members of the Global Association of Transgender Health Professionals describe how staff members of Adm. Rachel Levin, the undersecretary for health at the Department of Health and Human Services and a transgender woman herself, successfully urged the association to remove the proposed restrictions from its guidelines.
Whether and when teenagers should be allowed to undergo sex-reassignment treatment or surgery has been the subject of fierce political debate. Opponents argue that teenagers are too young to make such decisions, while supporters, including medical professionals, say young people with gender dysphoria face worsening depression and distress if the problem is left untreated.
In the United States, setting an age limit has been controversial from the start.
Draft guidelines published in late 2021 recommend lowering the minimum age to 14 for hormone treatment, 15 for mastectomy, 16 for breast implants and facial surgery, and 17 for genital surgery and hysterectomy.
The proposed age limit was removed in the final guidelines outlining standards of care, raising concerns within the international group and among outside experts about why the suggested age limit had disappeared.
Email excerpts made public this week shed light on possible reasons for the guideline change and highlight Adm. Levin's role as the Biden administration's top official on transgender issues. The excerpts are legal documents from a federal lawsuit challenging Alabama's ban on gender-affirming care.
One anonymous member of the WPATH guideline development group recalled a conversation he had with Sara Boateng, who was then Admiral Levin's chief of staff: “She is convinced, based on the rhetoric she is hearing in Washington and what we have already seen, that including a specific age below 18 will result in devastating legislation regarding transgender care. She wonders whether the specific age can be removed.”
Another email said Admiral Levin “was very concerned that including age (primarily for surgery) would impact access to health care for transgender youth and possibly adults. Apparently the situation in the U.S. is bad and she and the Biden Administration were concerned that including age on the document would make it worse. She asked us to remove the age.”
The excerpt was submitted by James Cantor, a psychologist and longtime critic of the gender-based treatment of minors, who used it as evidence that the international advisory group, called WPATH, was making decisions based on politics, not science, when developing the guidelines.
The emails were part of a report submitted in support of Alabama's ban on transgender medical care for minors. Emails from Admiral Levine's staff have not been made public. The plaintiffs argue that Dr. Cantor lacks expertise and his opinions are irrelevant, and are seeking to bar him from testifying in the case.
Admiral Levin and the Department of Health and Human Services did not respond to requests for comment, citing pending litigation.
Dr. Kanter said he filed the report to expose the contents of the organization's internal emails obtained by subpoena in the case, most of which remain sealed under protective orders. “What is being said publicly is completely different from the discussions that WPATH has in private,” he said.
Dr. Marcy Bowers, a gynecologic and reconstructive surgeon and president of WPATH, denied the allegations. “It's not a political issue. It was already clear that it was political,” said Dr. Bowers, who is a transgender woman. “WPATH does not take politics into account when making decisions.”
In other emails made public this week, some WPATH members expressed opposition to the proposed changes. “If our concerns are about the law (which I don't think they should be; ethically, it should be based on science and expert consensus), wouldn't including age be helpful?” one member wrote. “I'd love someone to explain how leaving out age helps fight the conservative anti-trans agenda.”
The international expert group ultimately removed the minimum age requirement in the eighth edition of the standards of care, released in September 2022. The guidelines reflect the first update in 10 years and are the first version of the standards to include a dedicated chapter on the medical care of transgender youth.
Because the field of adolescent gender transition care is relatively new, evidence about long-term outcomes is scarce, and most transgender youth in the United States who receive medical intervention are prescribed puberty-blocking drugs or hormones rather than surgery.
However, as the number of young people seeking such treatments soars, leading clinicians around the world are divided on issues such as the ideal timing and standards for medical intervention. Several European countries, including Sweden and the UK, have recently placed new restrictions on the use of gender-reassignment drugs for young people after reviewing the scientific evidence. In their health-care systems, the surgery is only available to patients aged 18 and over.
The email documents were unsealed by the U.S. District Court for the Middle District of Alabama and were filed in a lawsuit filed by civil rights groups, including the National Center for Lesbian Rights and the Southern Poverty Law Center, challenging Alabama's ban on behalf of five transgender young people and their families.
Transgender rights groups have gone to court to block laws like Alabama's, which have been approved in more than 20 Republican-majority states since 2021, but courts have been divided on the issue.
The Supreme Court announced Monday that it will hear a challenge to Tennessee's Adolescent Gender Medical Treatment Ban, which makes it a felony for doctors to administer gender-related treatment to minors, including puberty suppression drugs, hormones and surgery. The petition, filed by the Department of Justice, cites the WPATH guidelines as the leading “evidence-based clinical practice guidelines for the treatment of gender dysphoria.”
Additional emails cited in the new court documents suggest that the American Academy of Pediatrics also warned WPATH that it would not support the organization's recommendations if the guidelines set a new minimum age.
Mark Del Monte, chief executive of the American Academy of Pediatrics, noted in a statement Tuesday that the medical organization, which represents 67,000 U.S. pediatricians, does not endorse the international guidelines because it already has its own.
He said the society had sought to change the age limit in the guidelines because its policy does not recommend restricting surgery based on age.
Last summer, the Academy of Pediatrics reaffirmed its own guidelines published in 2018, but said for the first time it was commissioning an outside body to review the evidence.
The number of gender-related medical interventions for teenagers has been steadily increasing as young people seek such care. A Reuters analysis of insurance data estimated that 4,200 U.S. teens began estrogen or testosterone therapy in 2021, more than double the number four years ago. Surgeries are rarer, with the majority being mastectomies or top surgeries. Reuters estimated that 282 teens had top surgeries paid for by insurance in 2021.
Gender-related surgery on minors has become a focus for some politicians. Republican Governor Ron DeSantis of Florida has said surgeons should be sued for “disfiguring” children. In Texas, where the parents of a transgender child are under investigation for possible child abuse, Republican Governor Greg Abbott has called genital surgery on adolescents “genital mutilation.”
The final WPATH guidelines state that concerns about breast development in particular are associated with higher rates of depression, anxiety, and distress among transgender teens.
“The long-term effects of gender-affirming treatment initiated during adolescence are not fully understood, but the potential adverse health consequences of delaying treatment must be considered,” the guidelines state.
“Gender reassignment surgery is highly valued by those who need these services and is often life-saving,” Dr Bowers said.
