Health officials in the Biden administration have urged an international group of medical experts to remove age limits for surgery on adolescents from guidelines for caring for transgender minors, according to newly released court documents.
Officials feared minimum age limits could fuel growing political opposition to such treatments.
Email excerpts from members of the World Professional Association for Transgender Health detail how the staff of Admiral Rachel Levine, assistant secretary for health at the Department of Health and Human Services and a transgender woman herself, urged them to remove the proposed limits from the group’s guidelines, and apparently succeeded.
Whether and when teenagers can undergo transgender treatments and surgeries has become a fierce debate within the political world. Opponents say teens are too young to make such decisions, but supporters, including a slew of medical experts, say young people with gender dysphoria face depression and increasing problems if their problems are not addressed.
In the United States, setting age limits was controversial from the start.
The draft guidelines, released in late 2021, recommended lowering age minimums to 14 years for hormonal treatments, 15 years for mastectomies, 16 years for breast augmentation or facial surgeries, and 17 years for genital surgeries or hysterectomies.
The proposed age limits were eliminated in the final guidelines standards of carewhich raised concerns within the international group and among outside experts about why the age proposals had disappeared.
The email excerpts released this week shed light on possible reasons for the changes in guidance, and highlight Admiral Levine’s role as the Biden administration’s top figure on transgender issues. The excerpts are legal documents in a federal lawsuit challenging Alabama’s ban on gender-affirming care.
An excerpt from an unnamed member of the WPATH guidance development group recalled a conversation with Sarah Boateng, then Chief of Staff to Admiral Levine: “She is confident, based on the rhetoric she hears in DC, and on what we already have seen , that these specific mentions of ages under 18 will result in devastating trans healthcare legislation. She wonders if the specific ages can be extracted.”
Another email said that Admiral Levine was “very concerned that ages (particularly for surgeries) would impact access to care for trans youth and perhaps adults as well. Apparently the situation in the US is dire and she and the Biden administration were concerned that ages in the document would make matters worse. She asked us to remove them.”
The excerpts were submitted by James Cantor, a psychologist and longtime critic of gender treatments for minors, who used them as evidence that the international advisory group, called WPATH, made decisions based on politics, not science, in developing the guidelines.
The emails weree part of a report he submitted in support of Alabama’s ban on transgender medical care for minors. No emails from Admiral Levine’s staff have been released. The plaintiffs are trying to get Dr. to prevent Cantor from testifying in the case, claiming he has no expertise and that 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 report to uncover the contents of the group’s internal emails obtained through a subpoena in the case, most of which remain sealed due to a protective order. “What is being told to the public is completely different from WPATH’s private discussions,” he said.
Dr. Marci Bowers, a gynecological and reconstructive surgeon and president of WPATH, rejected that claim. “It wasn’t political, the politics were already clear,” said Dr. Bowers. “WPATH does not look at politics when making a decision.”
In other emails released this week, several WPATH members expressed disagreement with the proposed changes. “If we are concerned about legislation (which I don’t think we should be — we should be basing this on science and expert consensus if we want to be ethical), wouldn’t it be helpful to include the ages?” one member wrote. “I need someone to explain to me how removing the ages will help combat the conservative anti-trans agenda.”
The international expert group ultimately removed the age minimums in its eighth edition of the standards of care, released in September 2022. The guidelines reflected the first update in a decade and were the first version of the standards to include a special chapter on the medical treatment of transgender adolescents.
The field of gender transition care for adolescents is relatively new, and evidence on long-term outcomes is scarce. Most transgender adolescents who undergo medical interventions in the United States are prescribed puberty-blocking medications or hormones, not surgery.
But as the number of young people seeking such treatments has skyrocketed, leading doctors around the world are splitting over issues such as the ideal timing and criteria for the medical interventions. Several countries in Europe, including Sweden and the United Kingdom, recently imposed new restrictions on gender-biased medications for adolescents after reviewing the scientific evidence. In those countries’ health care systems, the surgeries are available only to patients aged 18 and over.
The email documents were released by the U.S. District Court for the Middle District of Alabama in a lawsuit challenging the Alabama ban brought by civil rights groups including the National Center for Lesbian Rights and the Southern Poverty Law Center on behalf of five transgender adolescents and their families.
Transgender rights groups have turned to the courts to block laws like Alabama’s that have been passed in more than two dozen Republican-controlled states since 2021, but the courts have been divided in their rulings.
On Monday, the Supreme Court announced it would hear a challenge to Tennessee’s ban on juvenile gender medicine, which makes it a crime for doctors to provide gender-related treatments to minors, including puberty blockers, hormones and surgery. The petition, filed by the Department of Justice, cited the WPATH guidelines as one of the most important “evidence-based guidelines for the treatment of gender dysphoria.”
Additional emails cited in the new court documents show that the American Academy of Pediatrics also warned WPATH that it would not endorse the group’s recommendations if the guidelines established 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 U.S. pediatricians, did not endorse the international guidelines because it already had its own guidelines.
He said the academy had tried to change the age limits in the guidelines because the group’s policy did not recommend age-based restrictions on surgery.
Last summer, the pediatrics academy reaffirmed its own 2018 guidelines but indicated that for the first time it would commission an external review of the evidence.
The numbers for all gender-related medical interventions for adolescents have been steadily increasing as more young people seek such care, a Reuters analysis Insurance data shows that 4,200 U.S. adolescents started estrogen or testosterone therapy in 2021, more than double the number four years earlier. Surgeries are rarer and the vast majority are mastectomies. or top operations. In 2021, Reuters estimated that 282 teens underwent top surgery paid for by insurance.
Gender-relevant surgeries for minors have been a focus of some politicians. Florida Gov. Ron DeSantis, Republican, has done so argued that surgeons should be charged 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 in adolescents “genital mutilation.”
The final WPATH guidelines state that issues related to breast development in transgender teens specifically have been linked to higher rates of depression, anxiety and fear.
“Although the long-term effects of gender-affirming treatments initiated in adolescence are not fully known, the potential negative health consequences of delaying treatment should also be considered,” the guidelines say.
“Gender affirming surgery is highly valued by those who need these services – in many cases they are lifesaving,” said Dr. Bowers.
