Florida Department of Health Guidance Against Transgender Youth Healthcare Contains False Statements and Misrepresentations and Should Not Be Used by Anyone (part 1)

FLDOH guidance against social transition, puberty blockers, or HRT for minors is not supported by cited documents from CMS, Sweden, Finland, England, or France

On April 20, 2022, the Florida Department of Health published three nonbinding documents containing sweeping and inaccurate claims about transgender youth and gender-affirming care: the press release “Florida Department of Health Releases Guidance on Treatment of Gender Dysphoria for Children and Adolescents”; the PDF “Treatment of Gender Dysphoria for Children and Adolescents”; and the PDF “Treatment of Gender Dysphoria for Children and Adolescents – Fact Check”. These documents are sloppily written, typically citing either low-quality opinion sources or selectively quoting from sources that clearly contradict the position FLDOH is attempting to support, and at times referring to documents that are not about even about children and adolescents.

The FLDOH misrepresents brief opinion pieces from individual authors in Catholic and psychoanalytic journals as constituting reliable literature reviews of existing knowledge on transgender healthcare and development. FLDOH makes invalid assumptions about desistance of childhood gender dysphoria at adolescence, misrepresents its clinical relevance, and then offers advice far beyond what this evidence supports. And the FLDOH simply lies about numerous national health authorities in the United States and abroad agreeing with the department’s entirely unsupported anti-trans guidance.

These documents represent another disgraceful failure of the FLDOH under the DeSantis administration to fulfill its basic mission of providing reliable, high-quality health information to all citizens of Florida. The fact is that everyone in the state, cis or trans, whether they care about transgender issues or not at all, is now being subjected to another insulting disservice from a department that is already bleeding credibility in the COVID-19 crisis, particularly under the leadership of state surgeon general Joseph A. Ladapo. What they’ve passed off as guidance here is nothing but an embarrassment, and its fatal flaws will be visible to anyone who bothers to follow its sources. Those sources are examined here.

The FLDOH document “Treatment of Gender Dysphoria for Children and Adolescents” states:

Social gender transition should not be a treatment option for children or adolescents. Anyone under 18 should not be prescribed puberty blockers or hormone therapy. Gender reassignment surgery should not be a treatment option for children or adolescents. . . . The Department’s guidelines are consistent with the federal Centers for Medicare and Medicaid Services age requirement for surgical and non-surgical treatment. These guidelines are also in line with the guidance, reviews, and recommendations from Sweden, Finland, the United Kingdom, and France.

Medicare coverage decision, 2021

FLDOH links to the federal Centers for Medicare & Medicaid Services Medicare Coverage Database article “Billing and Coding: Gender Reassignment Services for Gender Dysphoria (A53793)” (2021). The cited CMS article does not say anything about social gender transition or use of puberty blockers for children or adolescents, so the FLDOH’s guidance here is not “consistent” with CMS on “non-surgical treatment”. Policy and decisions made by CMS apply to coverage of treatments by Medicare and Medicaid, and the cited document is not a review of the literature informing transgender care across our lifespan, nor is it intended to be applied as clinical guidance for all medical providers at any step of transition care. CMS states the following as requirements for hormone therapy, not social transition (non-medical changes of name, pronouns, and gender presentation such as attire or hairstyle) or puberty blockers:

The criteria for cross sex hormone therapy are as follows:

1. Persistent, well-documented gender dysphoria;

2. Capacity to make a fully informed decision and to consent for treatment;

3. Member must be at least 18 years of age;

4. If significant medical or mental health concerns are present, they must be reasonably well controlled.

Medicare and Medicaid coverage of hormone therapy under this policy would require a trans person to be “at least 18 years of age”, while also requiring that they have “Persistent, well-documented gender dysphoria”. Trans people who reach the age of eligibility for hormone therapy under this policy will thus be expected to have experienced persistent gender dysphoria for some time before age 18. FLDOH guidance asserts that these youth who are suffering the distress of persistent gender dysphoria would not be allowed to ameliorate this suffering even by transitioning socially in that indefinite time, a prohibition which is not made anywhere in the cited CMS document.

Sweden National Board of Health and Welfare (Socialstyrelsen), March 2021

FLDOH describes the present guidance as “in line with the guidance, reviews, and recommendations” from Sweden and links to the March 2021 document “Good care of children and adolescents with gender dysphoria –  National knowledge support” from the National Board of Health and Welfare, or Socialstyrelsen. But the Socialstyrelsen document repeatedly recommends comprehensive assessment for possible treatment of trans youth with puberty blockers and cross-sex hormones – it is not at all consistent with the FLDOH guidance against puberty blockers, hormone therapy, or even social gender transition for anyone under 18. This is what Socialstyrelsen states on counseling and therapy for trans, gender-dysphoric and gender-questioning youth (via Google Translate):

Counselling, including psychotherapy and psychosocial support, is a prerequisite for quality care of gender dysphoria. During the assessment phase, access to counselling is crucial in order to promote well-founded decisions about gender reassignment treatments. Another reason is that treatment of gender dysphoria, though well-desired by the individual, often brings about medical and social strains. The patients as well as their relatives may need psychological and social support to deal with such strains. Patients may need such counselling during but also after gender reassignment treatments.

In contrast, under the FLDOH’s guidance, there would be no well-founded decisions to be made about gender reassignment treatments because those treatments would always be ruled out from the start. There would be no during or after such treatments, because there would be no treatments for anyone under 18. Page 110 of the Socialstyrelsen publication reads:

A precautionary principle, on the other hand, must not be so dominant that it leads to unacceptable consequences such as forcing patients to remain in a gender that they find foreign. For gender dysphoria among children and adolescents, it is then a matter of a young person being denied a period of adolescence in the gender that constitutes their identity: “Why should I not have a period of adolescence in the body with the gender I identify with?” A tangible and difficult suffering in a group of patients thus means that it may be inevitable to take certain risks, but it must be done in a transparent manner before the patient and so that the patient’s well-informed consent plays a decisive role.

This guidance emphasizes that trans children and adolescents must be fully informed of the risks that accompany these treatments so that they can meaningfully consent to that decision; it says nothing about such treatments being off the table for all trans youth under any circumstance. Instead, it says that forcing patients to remain in a gender that they find foreign is an unacceptable consequence. Page 112 describes conditions for offering cross-sex hormone therapy to youth:

This applies in particular to the issue of treatment with sex-opposite hormones, where more necessary conditions are specified. Gender dysphoria should be “diagnostically confirmed” and gender identity should be “strongly rooted”. Furthermore, the youth must demonstrate “mental maturity as well as knowledge and understanding of what results can be expected” and “in terms of possible medical and social risks and benefits”. In addition, “any psychological, medical and social problems” must have been considered and assessed so that they do not interfere with treatment. Of course, there are difficult trade-offs in relation to all these conditions, but they constitute reasonable positions based on a precautionary principle. They have not allowed this principle to become so rigorous that it does not take into account the profound identity problems that it entails when a young person has to develop gender characteristics in a gender to which the person is a stranger.”

According to FLDOH guidance, there would be no conditions under which this treatment is acceptable for youth; according to the Socialstyrelsen recommendations cited by the FLDOH guidance, “profound identity problems” result “when a young person has to develop gender characteristics in a gender to which the person is a stranger.”

Socialstyrelsen offers specific recommendations for prescribing puberty blockers without delay as well as hormone therapy:

• p. 52: “For adolescents with gender dysphoria, an approaching puberty means a great deal of mental strain. Healthcare should offer adolescents anti-puberty hormone therapy to reduce suffering. Older adolescents should also be offered treatment with sex-resistant hormones to initiate pubertal development that is consistent with gender identity.”
• p. 54: “The National Board of Health and Welfare’s recommendations: The health service should: ensure that treatment with puberty-inhibiting hormones is initiated without delay when the indication for treatment is established by the responsible psychiatrist; ensure that treatment with puberty-inhibiting hormones by adolescents with probable or confirmed sex dysphoria continues during the investigation thereafter, unless there are special reasons or if the conditions for treatment with anti-puberty hormones have changed.
• p. 55: “According to international guidelines and Swedish practice, young people with gender dysphoria should, under certain conditions, be offered hormone treatment at an early stage in order to slow down the development of puberty in the birth sex. A basic precondition for care to offer the intervention is that the gender dysphoria is probable or ensured. In addition to this, the youth must, as a minimum, have reached Tanner stage 2 in their puberty development, as gender dysphoria after the onset of puberty is more likely to persist over time. For many young people, the development of puberty leads to an increase in gender dysphoria, which is considered to be diagnostically important information. However, there are young people who have suffered from gender dysphoria for a long time and who have an obvious need for care without simultaneously reporting such an increase. An increased gender dysphoria in connection with the development of puberty should therefore be seen as something that strengthens the indication for treatment but not as a necessary medical criterion.”

On page 62, Socialstyrelsen states that youth may receive hormone therapy at 16 or earlier and should have already socially transitioned for some time:

In order for young people to be able to receive gender-opposite hormone treatment, it is required that gender dysphoria is ensured. Gender identity must be well established, which may mean that young people have lived socially in accordance with their gender identity since the onset of puberty-inhibiting treatment. The youth may also have consolidated their gender identity in other ways. Alternative explanations must have been excluded during the course of the investigation. The youth must have matured enough to understand what changes can be expected from a gender-opposite treatment and what medical and social consequences the treatment can entail. This is often expected to happen at the age of 16, but it can happen sooner or later.

Nothing about the guidance from Sweden cited by the FLDOH supports the department’s guidance that no one under 18 should socially transition or receive puberty blockers or hormone therapy.

COHERE Finland recommendation, June 2020

The FLDOH links to the June 11, 2020 recommendation “Medical treatment methods for dysphoria associated with variations in the gender identity of minors” by the Council for Choices in Health Care in Finland (COHERE Finland). However, contrary to the FLDOH guidance, the COHERE Finland recommendation lays out specific criteria for prescribing puberty blockers and hormone therapy to minors (via Google Translate):

If a pre-pubertal person has a clear symptom of sexual dysphoria before the onset of puberty that intensifies during puberty, he or she may be referred to the TAYS or HUS Gender Identity Research Group for evaluation of treatment that inhibits the progression of puberty. If no contraindications to early intervention are identified, inhibition of puberty with GnRH analogues (a drug that inhibits gonadotropin-releasing hormone activity) may be considered to prevent the development of secondary sex characteristics by biological sex. Adolescents who have already undergone puberty, who develop sexual anxiety but no other symptomatic symptoms requiring concomitant psychiatric care, and whose transgender experience is not lost with the opportunity to reflect their identity, may be referred to gender identity studies in the TAYS or HUS minority studies. Conversion hormone therapy (testosterone / estrogen and antiandrogen) should not be initiated until 16 years of age after diagnostic tests. In addition, GnRH analogue therapy, which blocks the hormonal function of their own gonads, is often started 3 to 6 months before conversion to hormone therapy.

These recommendations describe early use of puberty blockers and use of hormone therapy starting from age 16. It is not a recommendation against puberty blockers, hormone therapy, or social transition for anyone under 18.

NHS England Cass Review interim report, February 2022

FLDOH links to the Cass Review (“Independent Review of Gender Identity Services for Children and Young People”) commissioned by the English NHS. The interim report of this ongoing review, contradicting FLDOH guidance, recommends an expansion of services for trans and gender-questioning youth to provide more timely care, including ongoing counseling as well as possible assessment for puberty blockers or hormone therapy. The report states:

Any child or young person being considered for hormone treatment should have a formal diagnosis and formulation, which addresses the full range of factors affecting their physical, mental, developmental and psychosocial wellbeing. This formulation should then inform what options for support and intervention might be helpful for that child or young person.

This explicitly describes gender-affirming medical treatment as a possible option for children and young people, something under consideration – not something categorically ruled out as in the FLDOH guidance. The interim report recommends following up youth receiving these treatments within formal protocols in order to acquire better data; it does not recommend stopping such research in its tracks:

Prospective consent of children and young people should be sought for their data to be used for continuous service development, to track outcomes, and for research purposes. Within this model, children and young people put on hormone treatment should be formally followed up into adult services, ideally as part of an agreed research protocol, to improve outcome data.

The report calls for a significant expansion of services to assess these youth and reduce waiting times:

A fundamentally different service model is needed which is more in line with other paediatric provision, to provide timely and appropriate care for children and young people needing support around their gender identity. This must include support for any other clinical presentations that they may have. The Review supports NHS England’s plan to establish regional services, and welcomes the move from a single highly specialist service to regional hubs. Expanding the number of providers will have the advantages of: creating networks within each area to improve early access and support; reducing waiting times for specialist care; building capacity and training opportunities within the workforce; developing a specialist network to ensure peer review and shared standards of care; and providing opportunities to establish a more formalised service improvement strategy.

And the report describes how to obtain informed consent from trans children and adolescents for treatment with puberty blockers:

Given the uncertainties regarding puberty blockers, it is particularly important to demonstrate that consent under this circumstance has been fully informed and to follow GMC guidance by keeping an accurate record of the exchange of information leading to a decision in order to inform their future care and to help explain and justify the clinician’s decisions and actions. . . . Within clinical notes, the stated purpose of puberty blockers as explained to the child or young person and parent should be made clear. There should be clear documentation of what information has been provided to each child or young person on likely outcomes and side effects of all hormone treatment, as well as uncertainties about longer-term outcomes.

None of this is in agreement with FLDOH’s guidance that minors should be barred from puberty blockers, hormone therapy, and even socially transitioning.

France National Academy of Medicine (Académie nationale de médecine) press release, February 2022

The FLDOH cites a press release by France’s Académie nationale de médecine on “Medicine and gender transidentity in children and adolescents”, yet this press release also describes conditions under which youth should access puberty blockers or hormone therapy:

The National academy of medicine draws the attention of the medical community to the increasing demand for care in the context of gender transidentity in children and adolescents and recommends:

– A psychological support as long as possible for children and adolescents expressing a desire to transition and their parents;

– In the event of a persistent desire for transition, a careful decision about medical treatment with hormone blockers or hormones of the opposite sex within the framework of Multi-disciplinary Consultation Meetings;

The Académie has not called for withholding all access to puberty blockers or hormones for anyone under 18, and it hasn’t said anything about social transition. So the Florida Department of Health is 0 for 5 in citing Medicare, Sweden, Finland, England, and France as supporting its recommendations against social transition, puberty blockers, or gender-affirming hormone therapy. ■

Next: FLDOH anti-trans guidance attacks “low-quality evidence” for gender-affirming care, citing low-quality evidence for conversion therapy

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