When Dr. Ken Pang published one of the first large-scale analyses of gender-affirming care on transgender children, in 2018, the paper was celebrated as a vital contribution and even made its way to the home page of the r/Science subreddit.
Though the evidence was limited, the review suggested that hormone blockers and hormone replacement therapy could help alleviate gender dysphoria and make transgender youth feel more at home in their own bodies.
Four years later, Pang was shocked to learn that his research was being used by Florida’s Department of Health to justify denying gender-affirming care to all minors in the state. The department cited Pang’s work in a memo issued in April, after the passage of Florida’s so-called “Don’t Say Gay” law. The memo even recommends against social transition, which can include changes as simple as using new pronouns or wearing different clothing.
“It's one of those moments where your heart sinks,” Pang, a clinician and scientist at the Murdoch Children’s Research Institute in Australia, told VICE News. “One of the first principles [in the medical field] is to do no harm. So to be seeing the research we've done being utilized in this way—I was just dismayed by that.”
Pang had no idea that Florida was misusing his work until VICE News reached out for comment. And he’s not alone. VICE News spoke to 10 researchers who said they weren’t aware of the memo and that Florida’s Department of Health misstated their research; in fact, VICE News found that all 12 citations Florida presents against the use of gender-affirming care are either distorted or from a source with clear anti-trans bias. In crafting the document, Florida’s health department reverse-engineered rationale for a policy completely counter to research-based medical best practices.
“NO, this is NOT an appropriate use of our work,” another researcher cited in Florida’s memo told VICE News via email on the condition of anonymity, as they were not authorized by their institution to speak on the record. “This does not mean denying transgender youth and certainly not gender-affirming care!”
For decades, the standards of care put out by the leading medical professional organizations have been consistent on how to treat young people experiencing gender dysphoria. Despite these clear guidelines, Florida Gov. Ron DeSantis set the state on a campaign to vastly restrict the rights and medical resources available to transgender people when he signed the “Don’t Say Gay” bill into law in March. The new law bans any mention of sexual orientation or gender identity in kindergarten through third-grade classrooms and had an overall chilling effect on the freedoms of LGBTQ people in the state.
“NO, this is NOT an appropriate use of our work. This does not mean denying transgender youth and certainly not gender-affirming care!”
Less than a month after “Don’t Say Gay” became law, the Florida Department of Health released its memo attempting to provide a scientific explanation for denying gender-affirming care.
Then in June, Florida’s Agency for Health Care Administration also issued a new policy that no one, not even adults, would be able to access gender-affirming care through Medicaid. Rather than referring to the overwhelming body of research that shows positive outcomes of gender-affirming care, Florida instead commissioned hundreds of pages of new material—which did not go through a standard peer-review process—to justify the change. Florida Surgeon General Joseph Ladapo then wrote the state medical board and used these documents as the basis to “[recommend] against certain pharmaceutical, non-pharmaceutical, and surgical treatments for gender dysphoria.”
While particularly aggressive, Florida is hardly alone in its attacks. Just this year, 36 other states have also introduced or signed legislation restricting the rights of trans people.
Gender Dysphoria, described as significant distress due to a mismatch between someone’s gender identity and their gender assigned at birth, is included in the latest edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). It’s actually been in the DSM since 1980. And gender-affirming medical care has been practiced since the early 20th century.
Doctors have three tools to offer children with gender dysphoria: puberty blockers, hormone replacement therapy (HRT), and—perhaps most importantly—assuring the child and their family that their feelings are normal and should be supported. Puberty blockers given to pubescent children will halt the puberty process and can also aid medical transition later in adulthood, if desired. Teenagers and legal adults may elect to receive hormone replacement therapy, which promotes masculinization or feminization.
The effects of puberty blockers are reversible if stopped. Many, but not all effects of hormone replacement therapy are reversible, though infertility is a possible outcome. Gender-affirming genital surgery is not performed on minors.
Doctors speak out
Transgender people make up about one-half of 1 percent of the population—about half as many people who have red hair. And the number of young people who identify as transgender, nonbinary, or gender-nonconforming is growing, according to the CDC.
Yet when Pang started his comprehensive review of the available medical literature on healthcare for transgender kids, he found only 13 studies he could use. He and his team at the Murdoch Children’s Research Institute then published their findings in an article in Pediatrics, one of the premier medical journals in the field.
Florida’s memo denying gender-affirming care to kids contains one specific sentence which directly quotes Pang’s work: “One review concludes that ‘hormonal treatments for transgender adolescents can achieve their intended physical effects, but evidence regarding their psychosocial and cognitive impact is generally lacking.’”
Pang’s paper does contain that sentence, but he told VICE News that it’s taken vastly out of context. A lack of evidence doesn’t mean the treatment isn’t working or worthwhile—rather, that more research needs to be done to offer the best care possible. Pang’s paper is also five years old.
“It seems rather disingenuous for the Florida Department of Health to be using what they presumably know to be an out-of-date statement to support a blanket ban on gender-affirming care,” Pang said, “while at the same time ignoring the more recent evidence which shows, for instance, that gender-affirming medical care is associated with improvements in mental health."
“There is a lot more emerging literature. This is a fast-moving space,” Pang added. “And increasingly, the evidence shows that the provision of gender-affirming medical care is helpful.”
In July, for example, a researcher at Princeton, Dr. Kristina Olsen, published a landmark longitudinal study that followed more than 300 trans-identified youth, aged 3-12, for five years. By the study’s end, only 2.5 percent of the group had “retransitioned” to their assigned gender at birth.
“It seems rather disingenuous for the Florida Department of Health to be using what they presumably know to be an out-of-date statement to support a blanket ban on gender-affirming care.”
Another grossly misrepresented study in Florida’s memo relates to social transition.
“Social gender transition should not be a treatment option for children or adolescents,” the memo reads, linking to an article called “Not social transition status, but peer relations and family functioning predict psychological functioning in a German clinical sample of children with Gender Dysphoria,” published in the medical journal Clinical Child Psychology and Psychiatry.
A cursory glance at the article, especially by a non-medical professional, might lead someone to interpret it the way Florida’s health department does: as an argument against social transition.
But all five authors of the paper, responding to an inquiry from VICE News, issued a statement that Florida had egregiously misused their work, partly because the study involved a clinical sample of only 54 children.
“Therefore, our results cannot be generalized to every child diagnosed with gender dysphoria, and it did not look at long-term effects,” the statement reads. “On the contrary, the authors recommend every child should have the opportunity to explore their gender [emphasis theirs], which for some children may entail transitioning socially.”
Elisabeth Sievert, who’s the lead author and a researcher at the University of Erfurt in Germany, also explained that it’s not that social transition isn’t effective or necessary but rather that peer and family support can be even more important for the mental health of the child.
“We were not aware that the Florida Health Department was going to cite our work to issue a blanket ban on gender-affirming care for children. We were also not contacted by the Florida Health Department to double-check if the implications of our research were summarized correctly,” the joint statement continued.
Another distorted citation—one that not only appears in the Florida memo but is also heralded by anti-trans propagandists—comes from a 2015 study called “Gender Dysphoria in Childhood.” According to the Florida memo, this paper “states that 80% of those seeking clinical care will lose their desire to identify with the non-birth sex.”
But in an interview with VICE News, one of the paper’s co-authors, Dr. Thomas Steensma at the Amsterdam University Medical Center, said that number was taken wildly out of context.
Eighty percent, Steensma explained, related to a specific population of prepubescent children in The Netherlands. And, he added, even if it were true that 80 percent of children who identified as transgender later would eventually go back to identifying as their assigned sex at birth—”If you have 20 percent, why does that mean that you should not explore [gender identity] with a child?”
Citing Steensma’s work in an effort to ban trans-affirming care should also raise alarm bells because he’s the principal investigator at his university’s Center of Expertise on Gender Dysphoria and one of the world’s leading experts on medical care of transgender children. He helped create what’s known as the “Dutch protocol,” internationally accepted medical guidelines on how to administer puberty blockers to prepubescent children with gender dysphoria. Steensma is also a co-author of World Professional Association of Transgender Health’s (WPATH) forthcoming Standards of Care for the treatment of transgender children, which will be published this year.
Steensma was aware of his work being used as evidence against transgender medicine but did not know about Florida’s memo before being contacted by VICE News.
In fact, none of the researchers VICE News reached out to for this story had heard of the memo in which they were cited.
Florida’s memo, however, did catch the attention of World Professional Association of Transgender Health. Their U.S. affiliate (USPATH) issued a statement in response that unequivocally opposes several states’ recent efforts, including Florida’s, to deny transgender care to minors.
“Specifically, the justification included in recent Florida Department of Health guidelines claiming that such treatment confers an ‘unacceptably high risk of doing harm’ has numerous such misinterpretations and distortions,” the statement reads.
The U.S. Professional Association of Transgender Health takes issue with one theme, in particular, in Florida’s memo: that blockers and hormone replacement therapy present an “unacceptably high risk of doing harm,” due to a lack of clinical trials of gender-affirming medicine for minors.
“There are not a lot of double-blinded, randomized, controlled trials going on in pediatrics, because it's unethical,” said Dr. Maddie Deutsch, president of USPATH and the director of the transgender program at University of California-San Francisco. “The kids who are getting the placebo are going to know it.”
Deutsch explained that those forms of clinical trial tend to be used to test new forms of drugs used for new purposes; gender-affirming blockers and hormone replacement therapy, by contrast, have been around for decades and have long been shown to work.
Lots of forms of medicine already operate without the existence of “high-quality” data gathered in a randomized, double-blinded trial. That’s especially true in cases that would involve putting a vulnerable group on a placebo instead of a drug known to work—such as testing the use of antidepressants during pregnancy.
“You're not going to give a bunch of pregnant people who have depression placebos,” Deutsch said. “It would be unethical because people develop postpartum depression, [and it’s] a serious condition. It involves infanticide and suicide.”
The costs in such cases, in other words, are clearly outweighed by the benefits. “Are there potentially some unknown harms? Maybe,” Deutsch said. “But the benefits that we know about are so strong that we stick with it.”
“There are not a lot of double-blinded, randomized, controlled trials going on in pediatrics, because it's unethical. The kids who are getting the placebo are going to know it.”
When asked for comment about Florida’s rationale for denying gender-affirming care to minors, Jeremy Redfern, press secretary for the state’s Department of Health, said the data squarely supported the state’s policy.
“I don’t think you know how the ‘burden of proof’ works in the sciences,” Redfern said. “I’d suggest doing some reading and coming back once you understand.”
Arguing against well-established transgender medicine is a bit of a hobby-horse for Redfern, who’s responsible for communicating the tangible results of Florida’s healthcare policies. He often uses his personal Twitter account to tweet disinformation about gender-affirming care and troll members of the press when they seek clarity on the state’s policies.
In addition to distorting good science, the memo put out by Redfern’s department also includes citations to work by anti-trans activists.
One of them is Dr. William J. Malone, an Idaho-based physician and co-founder of the Society for Evidence-Based Gender Medicine (SEGM), which describes itself as a group “concerned about the lack of quality evidence for the use of hormonal and surgical interventions as first-line treatment for young people with gender dysphoria.” But the organization uses several of the same tactics—and the same citations—as Florida’s memo.
In fact, the Yale School of Medicine published an article in April that calls out the Society of Evidence-Based Gender Medicine as a small group of anti-trans activists “without apparent ties to mainstream scientific of professional organizations” that works to misrepresent science and serve as a basis for lawmakers to criminalize transgender care.
Malone’s writings have also cited the work of Oxford University epidemiologist and anti-vaccine activist Carl Heneghan, and he has also signal-boosted an anti-trans propaganda site called Reduxx.info.
In a statement to VICE News, Malone refuted that his organization is transphobic.
“[T]he field has become so politicized that even medical journals have succumbed to these pressures,” Malone wrote. “This is a big problem, and the results of such an irresponsible approach to medicine will harm the very people these researchers believe they are helping. At the same time, scientific debate is rarely platformed for the fear of being accused of ‘transphobia.’”
Another anti-trans source in the Florida memo is Dr. Paul Hruz, who teaches pediatric medicine at Washington University in St. Louis. But Hruz’s own faculty page does not describe any experience or expertise in treating gender dysphoria or transgender populations. He’s also been affiliated with the Alliance Defending Freedom (ADF), which has advocated for the forced sterilization of transgender people and is designated by the Southern Poverty Law Center as a hate group. In 2020, St. Louis Pride issued a statement condemning him.
In a statement to VICE News, Hruz dismissed St. Louis Pride’s “attacks” on him by people “unwilling to discuss the actual scientific evidence in this field.”
"I have been academically involved in scientific discussions related to the care of gender dysphoric youth for over a decade,” Hruz said. “I have also participated in the care of children with disorders of sexual development throughout my career."
Hruz did not elaborate on where or in what capacity he worked with such children, but he does not do so for his position at Washington University, according to Dr. Christopher Lewis, co-director of Washington University’s Pediatric Transgender Health program.
“The views expressed by Hruz are his own, and he is not speaking on behalf of the division of pediatric endocrinology,” Lewis told VICE News. “He is not a provider within either DSD [Differences of Sex Development] clinic or our transgender center.”
‘We’re talking about toddlers’
Florida’s memo came less than a month after an unequivocal statement of support of gender-affirming for minors issues by the U.S. Department of Health and Human Services (HHS): “Gender-affirming care for minors, when medically appropriate and necessary, improves their physical and mental health. Attempts to restrict, challenge, or falsely characterize this potentially lifesaving care as abuse is dangerous,” the agency wrote.
Jaime Jara, a mother of three in Kissimmee, Florida, has seen that impact up-close in her family. Her youngest child, Dempsey, began to socially transition at the age of 5. For Dempsey, that meant using “she” and “her” pronouns, growing out her hair, and wearing feminine clothes. Dempsey’s school honored her wishes and also allowed her to use the girls’ bathroom.
When Dempsey was born, Jara and her husband thought they’d be able to use their two older sons’ clothes as hand-me-downs. But Dempsey refused, throwing tantrums over any stereotypically masculine toy or piece of clothing given to her.
“We knew that she was gender-nonconforming as early as 2,” Jara told VICE News. “She just couldn't vocalize the word transgender. She didn't even have that vocabulary yet.”
“If we didn't let Dempsey socially transition, I don't know if Dempsey would still be here,” Jara added. “And I know that sounds so shocking, but even at 5—.” Jara then detailed several acts of severe self-harm reported to her by other parents of very young transgender children. “And we're not talking about the angsty teenager. We're talking about toddlers.”
For Dempsey—and many other transgender and gender-nonconforming children who have not yet gone through puberty—a transition is solely a “social” transition: new pronouns, new clothes, new hair, sometimes a new name (though Dempsey kept hers), and affirmation by peers and family. But even these simple acts are now verboten in Florida.
“She's a late bloomer, so she's probably not going to be on blockers for another couple of years,” Jara said. “But this is still a problem for us, because they're saying in that memo you can't affirm your kid by even letting them socially transition.”
Jara is a high school history teacher and recently attended a teacher training on Holocaust education. The resonance, she said, was hard to ignore. “First, they're systematically stripping away rights. Then you're starting to have to plan—people in certain countries were like, ‘OK, if we can leave fast enough, this won't affect us.’ There are so many parallels.”
Despite Florida’s sweeping efforts, which have been described as “genocide,” Jara remains determined to get her daughter the care she needs. If and when the time comes for Dempsey to take hormone blockers, Jara is optimistic that their doctor will find a way to prescribe them. What’s more worrying to her, though, is the overall political climate that seems to be getting more hostile by the day.
“Are we going to have to leave Florida? Are we going to have to move? And then it gets you to start thinking—OK, well, DeSantis is throwing out breadcrumbs that he's going to run for president. What is the United States landscape going to look like if he becomes president?
“So, yeah, it's scary. We just want to live. I just want my kid to live, that's all.”
Correction 8/3: The text of this article has been updated to reflect that puberty blockers are recommended only for pubescent children. We regret the error.
Update 8/5: The description of Reduxx.info and Carl Heneghan have been updated in this story.
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