Newly unsealed court documents reveal that health officials in the Biden administration pressed an international group of medical experts to remove age limits for adolescent surgeries from guidelines for transgender minors. The officials feared that age minimums could exacerbate political opposition to these treatments.
Emails from members of the World Professional Association for Transgender Health (WPATH) indicate that staff for Admiral Rachel Levine, assistant secretary for health at the Department of Health and Human Services, urged them to drop the proposed age limits from the group’s guidelines. Admiral Levine, herself a transgender woman, succeeded in influencing these changes.
The debate over whether teenagers should be allowed to undergo transgender treatments and surgeries is contentious. Opponents argue that teenagers are too young to make such decisions, while supporters, including numerous medical experts, contend that young people with gender dysphoria face depression and worsening distress if their issues go unaddressed.
Setting age limits in the United States has been controversial. Draft guidelines released in late 2021 suggested lowering age minimums to 14 for hormonal treatments, 15 for mastectomies, 16 for breast augmentation or facial surgeries, and 17 for genital surgeries or hysterectomies. However, these age limits were removed in the final guidelines, raising concerns among international and outside experts about why the age proposals vanished.
Email excerpts released this week illuminate possible reasons for these guideline changes and highlight Admiral Levine’s role as a key point person on transgender issues in the Biden administration. The excerpts are part of a federal lawsuit challenging Alabama’s ban on gender-affirming care. One excerpt from an unnamed WPATH guideline development group member recounted a conversation with Sarah Boateng, then Admiral Levine’s chief of staff. Boateng reportedly expressed concern that specifying ages under 18 could result in damaging legislation for trans care. Another email noted that Admiral Levine was very concerned that having ages specified (especially for surgeries) would affect access to care for trans youth and potentially adults, urging the removal of these age specifications.
These excerpts were filed by James Cantor, a psychologist and critic of gender treatments for minors, who used them as evidence that WPATH was making politically motivated decisions rather than basing guidelines on scientific evidence. Cantor’s report supports Alabama’s ban on transgender medical care for minors. Plaintiffs in the case seek to bar Cantor from testifying, claiming he lacks relevant expertise.
Admiral Levine and the Department of Health and Human Services did not comment, citing pending litigation. Cantor stated that his report aimed to expose discrepancies between WPATH’s public statements and private discussions. Dr. Marci Bowers, WPATH president, denied political motivations, stating that WPATH bases its decisions on science and expert consensus, not politics.
Additional emails from WPATH members showed some disagreement with removing age limits. One member argued that including ages would help fight against conservative anti-trans legislation. Ultimately, WPATH’s eighth edition of the standards of care, released in September 2022, omitted age minimums. This edition was the first to include a chapter dedicated to medical treatment for transgender adolescents.
Gender transition care for adolescents is a relatively new field with limited long-term outcome evidence. Most transgender adolescents in the U.S. receive puberty blockers or hormones rather than surgeries. However, as the number of adolescents seeking such treatments has increased, clinicians worldwide have debated the ideal timing and criteria for medical interventions. Some European countries, including Sweden and Britain, have recently imposed new restrictions on gender medications for adolescents following scientific reviews. In these countries, surgeries are only available to patients 18 and older.
The email documents were released by the U.S. District Court for the Middle District of Alabama in a case challenging Alabama’s ban on transgender medical care for minors. Transgender rights groups have turned to the courts to block such laws, which have been approved in over 20 Republican-controlled states since 2021. The courts have been divided in their rulings.
The Supreme Court recently announced it would hear a challenge to Tennessee’s ban on youth gender medicine, which criminalizes providing any gender-related treatment to minors. The Department of Justice petition cited WPATH guidelines as primary evidence-based practice guidelines for treating gender dysphoria.
Emails in the new court filings also suggest that the American Academy of Pediatrics (AAP) warned WPATH it would not endorse the group’s recommendations if new age minimums were set. The AAP, which represents 67,000 U.S. pediatricians, did not endorse the international guidelines, as it already had its own policies in place without age-based surgery restrictions. Last summer, the AAP reaffirmed its 2018 guidelines and announced an external review of the evidence.
As the number of adolescents seeking gender-related medical interventions has increased, the debate over appropriate age limits and criteria for these treatments continues. The final WPATH guidelines emphasize the potential negative health consequences of delaying treatment and highlight the value of gender-affirming surgery for those who need it, calling it lifesaving in many cases.
