Transgender medical interventions pose a tremendous risk to children and adolescents because they create a host of irreversible physical consequences, even though the vast majority of children eventually grow out of their dysphoria and become comfortable in the bodies they were born with.

  • According to the World Professional Association for Transgender Help (WPATH) transgender standards of care,[1] which HHS relies on, “In most children, gender dysphoria will disappear before, or early in, puberty.” Indeed, WPATH’s recommended studies demonstrate that up to 94% of children referred for gender dysphoria (77-94% in one set of studies and 73-88% in another) will grow out of their gender dysphoria naturally.[2]  

  • Other researchers note that “[e]very study that has been conducted on this has found the same thing. At the moment there is strong evidence that even many children with rather severe gender dysphoria will, in the long run, shed it and come to feel comfortable with the bodies they were born with.”

The physical changes are intense and can cause massive distress for the many children who grow out of their dysphoria.

  • The physical effects of hormone therapy in female to male patients include “deepened voice, clitoral enlargement (variable), growth in facial and body hair, cessation of menses, atrophy of breast tissue, and decreased percentage of body fat compared to muscle mass.”

  • The effects of hormone therapy in male to female patients include “breast growth (variable), decreased erectile function, decreased testicular size, and increased percentage of body fat compared to muscle mass.”[3]

  • WPATH guidance acknowledges that if a child reverts back to his or her natal gender, this can be “highly distressing.”[4] Distress is only heightened if a child is dealing with irreversible physical changes caused by hormone therapy, such as a permanently deepened voice for a young girl.

Transgender medical interventions also carry very serious medical risks:

  • In another report relied on by HHS, the Institute of Medicine of the National Academies noted that transgender individuals “may be at increased risk for breast, ovarian, uterine, or prostate cancer as a result of hormone therapy.”[5]

  • Further, “longer duration of hormone use . . . may well exacerbate the effects of aging, such as cardiac or pulmonary problems.”[6]

  • Hormone therapy may impact fertility, although little research has been conducted on the reproductive health needs of transgender individuals.[7]

  • WPATH similarly identified the following potential health risks associated with hormone therapy: cardiovascular disease, type 2 diabetes, gallstones, venuous thromboembolic disease, and hypertension.[8]

  • WPATH also acknowledged concerns about the negative effects of puberty suppression medicine on bone development and height.[9]

The Transgender Mandate requires private insurers and most employers to cover transgender therapy and removes the ability of doctors to decide whether it is in the best interest of their patients. But HHS exempts its own health insurance plans—Medicare and Medicaid—from the mandate. In fact, HHS’s own medical experts found that the available evidence does not justify requiring coverage of transgender medical intervention, even in adults, and such procedures could cause patients harm:

  • “Based on a thorough review of the clinical evidence available at this time,” HHS’ medical experts wrote, “there is not enough evidence to determine whether gender reassignment surgery improves health outcomes for Medicare beneficiaries with gender dysphoria.”[10] Even with adult populations, the HHS medical experts noted that “There were conflicting (inconsistent) study results—of the best designed studies, some reported benefits while others reported harms.”[11]

The Government also exempts its own military doctors from the mandate. In fact, TRICARE policy is clear that a doctor should never be forced to perform a gender transition procedure the doctor is uncomfortable providing: 

  • “In no circumstance will a provider be required to deliver care that he or she feels unprepared to provide. . . ."[12]

Yet HHS is unwilling to provide the same protection to doctors in private practice. 


[1] Nondiscrimination in Health Programs and Activities, 81 Fed. Reg. 31375, 31435 n. 263 (May 18, 2016) (citing World Professional Association for Transgender Health (WPATH), Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People (7th ed. 2012), http://www.becketfund.org/wp-content/uploads/2016/08/WPATH-Standards-of-Care2c-V7-Full-Book-1.compressed.pdf; Institute of Medicine of the National Academies, The Health of Lesbian, Gay, Bisexual and Transgender People: Building a Foundation for Better Understanding (2011); http://www.becketfund.org/wp-content/uploads/2016/08/The-Health-of-LGBT-People_Book.pdf).

[2] WPATH, supra note 1, at 11 (“Gender dysphoria during childhood does not inevitably continue into adulthood. Rather, in follow-up studies of prepubertal children (mainly boys) who were referred to clinics for assessment of gender dysphoria, the dysphoria persisted into adulthood for only 6–23% of children (Cohen-Kettenis, 2001; Zucker & Bradley, 1995). Boys in these studies were more likely to identify as gay in adulthood than as transgender (Green, 1987; Money & Russo, 1979; Zucker & Bradley, 1995; Zuger, 1984). Newer studies, also including girls, showed a 12–27% persistence rate of gender dysphoria into adulthood (Drummond, Bradley, Peterson-Badali, & Zucker, 2008; Wallien & Cohen-Kettenis, 2008).”).

[3] WPATH, supra note 1 at 35-36.

[4] WPATH, supra note 1 at 17.

[5] Institute of Medicine of the National Academies, supra note 1, at 264. 

[6] Institute of Medicine of the National Academies, supra note 1, at 265. 

[7] Institute of Medicine of the National Academies, supra note 1, at 204. 

[8] WPATH, supra note 1 at 40.

[9] WPATH, supra note 1 at 20.

[10] Centers for Medicare & Medicaid Services, Proposed Decision Memo for Gender Dysphoria and Gender Reassignment Surgery (June 2, 2016), at http://www.becketfund.org/wp-content/uploads/2016/08/proposed-memo.pdf (emphasis added).

[11] Id. (emphasis added).

[12] Mem. from Karen S. Guice, Acting Assistant Sec'y of Def. to Assistant Sec'y of the Army, et al., Subject: Guidance for Treatment of Gender Dysphoria for Active and Reserve Component Service Members 2-3 (July 29, 2016),  http://www.becketfund.org/wp-content/uploads/2016/12/Exhibit-B-Guidance-for-Treatment-of-Gender-Dysphoria-Memo-002.pdf