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Florida memo on gender dysphoria contradicts leading medical guidance

(iStock/The Washington Post)
7 min

This story has been updated.

In a surprise move Wednesday morning, Florida’s surgeon general released a memo to health-care workers on gender-affirming care. It advises physicians against prescribing puberty blockers or hormone therapy for transgender youths and states that social gender transition — a nonmedical process in which a person uses a name, pronouns and/or clothing that matches their gender identity — should “not be a treatment option for children or adolescents.”

The memo directly contradicts guidance from the U.S. Department of Health and Human Services on gender transition, as well as best practices as outlined by the country’s largest medical organizations. In a statement published alongside a “fact check” of the evidence, Florida Surgeon General Joseph Ladapo questioned the HHS’s guidelines and its motives, accusing it of “injecting political ideology into the health of our children.”

“Children experiencing gender dysphoria should be supported by family and seek counseling, not pushed into an irreversible decision before they reach 18,” Ladapo said.

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The memo, which is not legally binding, dismisses evidence that supports the benefits of gender-affirming care, including its impact on the mental health of trans youths.

“Systematic reviews on hormonal treatment for young people show a trend of low-quality evidence, small sample sizes, and medium to high risk of bias,” the state’s new guidance argues.

Citing a lack of “conclusive evidence,” as well as the potential for long-term, irreversible effects, the state surgeon general advises against prescribing puberty blockers and hormone therapy to anyone under 18 years old; states that gender reassignment surgery should not be an option for children or adolescents; and asserts that social transition should not be a treatment option.

The memo adds that the new guidelines do not apply to children or adolescents who are intersex.

Physicians’ groups, trans rights advocates and civil rights groups denounced the memo, which they say was a politically motivated attempt to create confusion over established medical practices. The American Civil Liberties Union called the guidance a “desperate effort to sow lies and fear about transgender youth, their parents, and their health care.”

“The Florida department of health is attempting to demonize life-saving, critical, medically-necessary healthcare for transgender youth,” said Daniel Tilley, legal director for the ACLU of Florida in a statement.

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The Endocrine Society, a global organization representing more than 18,000 physicians who specialize in studying and treating hormone issues, called on the state health agency to rescind its bulletin and “allow physicians to provide evidence-based care.”

“Medical evidence, not politics, should inform treatment decisions,” the group said in a statement shared with The Washington Post. “The Florida Department of Health’s bulletin cites only a handful of studies. This is in contrast to formal medical guidelines that comply with the Institute of Medicine’s standards. Our Clinical Practice Guideline adheres to these national standards and cites more than 260 scientific studies.”

The guidance comes amid an unprecedented wave of legislation aiming to curb the rights of LGBTQ Americans, particularly those of trans youths. Conservative state lawmakers have increasingly proposed bills that would criminalize gender-affirming care for minors, including in Florida. State Rep. Anthony Sabatini (R) introduced such legislation last year, but the bill never made it out of committee.

Legislation isn’t the only tool politicians have used. In Texas, Gov. Greg Abbott (R) issued a directive earlier this year ordering the state’s child welfare agency to investigate reports of children receiving gender-affirming care as “child abuse.”

The Biden administration has spoken out against such actions. Last month, the White House asserted that trans people have a constitutional right to gender-affirming health care.

The largest medical organizations in the country — including the American Medical Association, the American Psychiatric Association and the American Academy of Pediatrics — have publicly supported gender-affirming care. For trans minors, that typically includes social transitioning and may include nonsurgical treatments, such as puberty blockers or hormone therapy.

The Endocrine Society notes that only reversible treatments to delay puberty are recommended for younger adolescents, and that the same treatment has been used for decades to treat early-onset puberty for cisgender girls.

“While the Florida Department of Health policy expresses concern about surgery being offered to teens younger than 18, the reality is that gender-affirming surgery is generally limited to adults who meet medical and psychological requirements,” it said in its statement.

While conservative lawmakers across the country have argued that gender-affirming treatments such as puberty blockers are “experimental,” few bills have explicitly challenged social transitioning. For gender-diverse minors, this typically means changing their hairstyle or clothing, and HHS’s guidance points to “gender-affirming hairstyles” as one example.

The Florida guidance is rife with misinformation, said Jack Turban, chief fellow in child and adolescent psychiatry at Stanford University School of Medicine, where he researches the mental health of trans youths.

“It’s shocking to see a public health organization spread healthcare misinformation,” Turban said in an email to The Post. “There are false statements on nearly every line of this document.”

Turban said Ladapo cited “outdated and irrelevant” review articles, as well as omitted key evidence published over the past several years that links gender-affirming medical care to improved mental health outcomes.

Ladapo’s guidance cites a controversial paper published in the International Review of Psychiatry that found that 80 percent of those seeking clinical care for gender issues “will lose their desire to identify with the non-birth sex.” The paper has been criticized by Turban and other experts for its methodology: They say the study includes a large cohort of children who did not actually meet the criteria for gender dysphoria, meaning they were not transgender.

A 2021 study by Turban and researchers from the Fenway Institute and Harvard Medical School found that 13.1 percent of people who identify as transgender have “detransitioned” at some point in their lives, but this is driven not by regret, but by discrimination, stigma and family pressure.

Ladapo, the state’s top doctor, has been the subject of controversy since he was confirmed by the Florida state Senate earlier this year. He has criticized pandemic-era safety measures embraced by the vast majority of the medical community, including quarantines, vaccines and wearing face masks.

Jeremy Redfern, press secretary for the Florida Department of Health, responding to questions about why the office’s new recommendations run counter to those of the wider medical establishment, repeated Ladapo’s assertion that the evidence was inconclusive.

“The burden of proof falls on [major medical institutions] to support their claims,” Redfern said. “We’ve provided an analysis of the current evidence and made recommendations based on that evidence.”

Chandler Martin, a second-year medical student in Fort Lauderdale, said receiving Wednesday’s memo from an official health-care governing body “was incredibly shocking and disturbing.”

The part of the memo Martin believes is most likely to do harm is the advice against social transitioning.

“It is well known to anyone remotely aware of trans issues that trans suicide rates are among the highest of any minority cohort,” Martin said. “Those rates are highest in trans people of color and trans youth.”

“The best way to mitigate trans suicide rates, outside of any medical interventions or hormone therapies, is to create an accepting and loving environment for these at-risk populations, and to allow them to live as who they feel they truly are,” he added.

Turban echoed that sentiment.

“The suggestion that social transitions should be avoided for trans youth goes against all existing medical guidelines and data,” he said. “Refusing to allow a child to socially transition results in shame, damaged relationships between the child and the [provider], and damaged relationships between the child and their parents — all of these result in anxiety, depression and bad mental health outcomes.”

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