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The U.S. Department of Health and Human Services has released a comprehensive, peer-reviewed report highlighting weak evidence and potential harms in gender transition procedures for minors, sparking sharp criticism from medical groups and activists.

The U.S. Department of Health and Human Services on Wednesday released the final version of a 410-page report comprehensively reviewing the scientific literature regarding the provision of gender transition procedures. The document fine-tuned a preliminary version of the report published on 1 May, which has been hurried across the finish line to comply with a 90-day deadline given by President Trump.

Amid 14 chapters in five parts, the review “describes the very low-quality evidence underpinning treatment approaches” and “contains an extensive description of potential or plausible harms associated with certain treatment options (namely, hormonal interventions and surgeries).” Most importantly, the report solicited criticism from a broad cross-section of medical opinion, resulting in a product that was not only robust but peer-reviewed.

HHS also published two supplemental documents, a 185-page appendix containing its full “Overview of Systematic Reviews” and a 241-page peer review supplement.

The earlier version evaluated 17 systematic reviews and critiqued the existing literature for methodological flaws (the final version appears to be substantially similar, although anyone claiming to have read all 836 pages of the documents published less than 24 hours ago could not have done so carefully).

The earlier version also met with instant criticism from LGBT activist organisations and — at the risk of being redundant — from mainstream medical organisations. The American Academy of Pediatrics, for example, claimed the report “misrepresents the current medical consensus”, even though no such consensus exists. The preliminary review was also criticised for a lack of transparency, as information about the methodology, authorship, and potential conflicts of interest had not been disclosed.

Rigorous Process

In its final form, the HHS review conclusively lays to rest those concerns about transparency. It published the full list of authors who contributed to the report, including researchers at the Massachusetts Institute of Technology, Duke University, Baylor College of Medicine, Colorado State University, the University of South Florida, the Manhattan Institute, the Society for Evidence-Based Gender Medicine, and Evidence Bridge; eight out of nine authors hold a doctoral-level degree. It also disclosed statements about potential conflicts of interest.

Most importantly, the final version of the report included a peer review process. Comments from nine peer reviewers (both groups and individuals), as well as the authors’ responses to every review, were published in a lengthy supplement. Most of the reviewers — academics in their own right — reacted positively, calling the report well-argued, persuasive, and sound on methodology; they offered minor critiques or suggestions for improvement.

However, one review came from the American Psychiatric Association (APA), a proponent of gender transition procedures for minors. The APA took the opportunity to deliver a broadside against the Trump administration’s report.

“Our conclusions are that while the HHS Report purports to be a thorough, evidence-based assessment of gender-affirming care for transgender youth, its underlying methodology lacks sufficient transparency and clarity for its findings to be taken at face value,” the APA declared. “Key elements including literature selection criteria, analytical frameworks, and justification for excluding other studies, and key findings in studies on which the Report relies, are either underexplained or absent.” The APA concluded by listing 16 studies that they said the report should consider.

Alas, this list of studies — likely provided to lacquer on a coating of “expertise” to the otherwise immoderate reply — proved to be its greatest weakness. In response, the report’s authors simply stated that they had discussed 12 of the 16 studies already, that three studies did not concern the population in question (minors), and that the other one was published after their preliminary review, but didn’t qualify anyway. Such a response provokes the question, did the APA reviewers even read the report they condemned? (Perhaps they did, and they simply neglected to dig through the 185-page appendix, where all their questions were answered.)

As for the allegation about the report’s methodology, one peer review came from two methodologists at the Belgian Centre for Evidence-Based Medicine, who “commended its robust methodology,” the authors argued. “They identified no major issues related to its design or conclusions, noting that ‘the final results are described transparently and are easy to follow’ and that ‘there are also many tables with necessary and relevant information.’”

Readers may wonder whether the fault really lies with the APA. Perhaps other medical associations would have reviewed the report more thoroughly, fairly, or at least with better critiques. In fact, “HHS invited the American Academy of Pediatrics and the Endocrine Society to contribute their evidence to this report,” the agency stated. “Both organisations declined to participate.”

Bitter Backlash

Notwithstanding the crickets of criticism raised in the peer review process, other and less qualified LGBT activists have raised new objections since its publication. “They very clearly picked their own reviewers to tell them what they wanted to hear,” complained Kellan Baker, a policy advisor for the far-left Movement Advancement Project. “They did not engage with anyone with actual clinical expertise in the care of trans youth. It is a very small loop of people who have already been on record, as they would call themselves ‘sceptics’, — I think it’s fair to call them opponents of care for trans young people.”

Another way of viewing the same data is that only “a very small loop of people” in academia is willing to brave the hatred, threats, and professional consequences that follow anyone willing to speak the truth “on record” about the harms of gender transition procedures for minors.

In any event, the criticism misses wide. One reviewer was Richard Santen, a former president of the Endocrine Society, one of the earliest medical associations to become captured by transgender ideology. In any event, the unrequited invitations for major medical organisations to review the report contradict the suggestion that HHS “picked their own reviewers to tell them what they wanted to hear.”

Even the study’s authors “are very politically and ideologically a diverse group,” responded Dr Leor Sapir of the Manhattan Institute, one of the few conservatives involved. “Most of the authors are liberals, Democrats. They wouldn’t vote for Trump if he forced them to. This is a bipartisan initiative.”

The federal government also has standards for peer review. On 14 January 2005, the Office of Management and Budget published a rule, “Final Information Quality Bulletin for Peer Review”, that “requires each agency to subject ‘influential’ scientific information to peer review prior to dissemination.” The rule “provides agencies broad discretion in determining what type of peer review is appropriate and what procedures should be employed to select appropriate reviewers.” But there are some guidelines.

“Regardless of the peer review mechanism chosen, agencies should strive to ensure … both scientific integrity and process integrity,” the rule explains.

“‘Scientific integrity,’ in the context of peer review, refers to such issues as ‘expertise and balance of the panel members; the identification of the scientific issues and clarity of the charge to the panel; the quality, focus and depth of the discussion of the issues by the panel; the rationale and supportability of the panel’s findings; and the accuracy and clarity of the panel report.’ ‘Process integrity’ includes such issues as ‘transparency and openness, avoidance of real or perceived conflicts of interest, a workable process for public comment and involvement,’ and adherence to defined procedures.”

On a practical level, this means that agencies should choose reviewers “who represent the necessary spectrum of knowledge” and “a diversity of scientific perspectives.” HHS did so here. “On most controversial issues,” the rule adds, “Inviting reviewers with competing views on the science may lead to a sharper, more focused peer review.” By selecting as reviewers both opponents of gender transition procedures for minors and the medical associations that advocate for them, the HHS report fulfils this directive better than if it had excluded either one perspective or the other.

The basic problem for critics of the report is that the pro-transitioning side had little to argue in the way of actual arguments or evidence against the report. “They were given the chance to show mistakes, show errors. And they were not able to identify any,” said Sapir. “They can condemn the report all they want, but they were not able to identify a single mistake. Not one.”

The HHS report made no formal policy recommendations, but it provides a solid appraisal of the underlying scientific evidence that will better inform policy decisions going forward. “This report marks a turning point for American medicine,” cheered National Institutes of Health Director Jay Bhattacharya.” “The evidence in it meticulously documents the risks the profession has imposed on vulnerable children.”

HHS Secretary Robert Kennedy contended that “The American Medical Association and the American Academy of Pediatrics peddled the lie that chemical and surgical sex-rejecting procedures could be good for children. They betrayed their oath to first do no harm, and their so-called ‘gender-affirming care’ has inflicted lasting physical and psychological damage on vulnerable young people. That is not medicine — it’s malpractice.”

“The HHS Report at long last documents the need for protecting children from the harmful effects of the insane madness of hormones and surgery,” said FRC Senior Fellow Walt Heyer. “As someone who started publishing articles about protecting children from hormones as far back as January 2015, I’m thrilled HHS under the guidance of the Trump administration has published this report that echoes everything people on the ‘right side’ have been saying for many years. Bravo to HHS.”