USPATH and WPATH Confirm Gender-Affirming Health Care is Not
Experimental; Condemns Legislation Asserting Otherwise
March 22, 2023 - The United States Professional Association for Transgender Health(USPATH) and the World Professional Association for Transgender Health (WPATH)
denounces the emergency regulation halting gender-affirming healthcare for transgender andgender diverse (TGD) children and adolescents issued by Missouri Attorney General Andrew
Bailey as lacking scientific grounding.
The WPATH Standards of Care for the Health of Transgender and Gender DiversePeople, now in its 8th version (SOC8), is the foremost evidence-based guideline for theprovision of TGD healthcare. SOC8 is based on the best available science with input from over
100 global medical professionals and experts and represents best-practice guidelines for theprovision of gender-affirming healthcare. Gender-affirming interventions are based on decadesof clinical experience and research and are not considered experimental. Gender affirming
hormone therapy (GAHT) is a component of widely accepted medically necessary care for TGD
people.
In addition to WPATH, the largest establishment medical associations (including theAmerican Medical Association, the American College of Physicians, the Endocrine Society, theAmerican College of Obstetricians and Gynecologists, the American Academy of Pediatrics, andthe American Psychiatric Association, among others) have supported the provision of genderaffirming care for TGD people as medically necessary care.
Attorney General Bailey’s claims were either taken out of context, cherry-picked, or fromunverified sources. In some situations, the excerpted statements used in the regulation are later
contradicted in the same study or article from which they were pulled. The resulting regulationfrom the AG’s office strings together non sequitur misinformation in their attempt to prohibit safeand legal health care. For example, there are no formal Food and Drug Administration (FDA)
approvals for many hormonal therapies across all of endocrinology, not limited to hormone
replacement therapies for TGD patients, despite the medications themselves having been
approved by the FDA. FDA regulations do not directly or explicitly prohibit the promotion of offlabel uses and, per the FDA Modernization Act of 1997, the FDA must review all materials andpeer-reviewed articles about off-label use. 1 Off-label use is neither uncommon nor illegal.

1Ventola, C. Lee. “Off-Label Drug Information.” Pharmacy and Therapeutics, vol.34, no. 8, Aug. 2009, pp.
428–40. PubMed Central, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2799128/.

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AG Bailey’s information about brain swelling and blindness as a result of puberty
blockers or hormone suppression therapy was taken from a 2022 FDA statement thatreferenced six patients who identified a plausible association between gonadotropin-releasing
hormone (GnRH) and pseudotumor cerebri. Of the six cases that were identified, all wereassigned female at birth and five were undergoing treatment for precocious puberty - only one
case identified was for transgender care. 2 According to the Mayo Clinic, pseudotumor cerebri
can occur in children but is most common in women of childbearing age who are obese. The
most common treatment for pseudotumor cerebri is weight loss. 3 Notably, at the time of theFDA’s review, symptoms had resolved in three patients and were resolving in another. In thesame statement, the FDA asserts that “the incidence rate of pseudotumor cerebri associatedwith GnRH agonist use in pediatric patients could not be reliably established due to the small
number of cases and data limitations.” 4 The full FDA statement asserts a lack of information todraw such conclusions, yet AG Bailey has done so in his efforts to ban gender-affirming care.
AG Bailey’s reference to Sweden’s National Board of Health and Welfare (NBHW)
recent declaration about the risks of puberty suppression therapy and gender-affirming hormone
replacement therapy outweighing the possible benefits is also taken out of context; in their press
release, NBHW recommends restraint and further study regarding GAHT for people under 18,
not a total ban on care. 5 Furthermore, this statement includes no citations to literature orstudies. In a July 2022 article published by the American Academy of Pediatrics, Dr. Kristina R.
Olson et al reports that five years after their initial social transition, 97.5% of TGD youth
continued to identify as transgender or nonbinary. 6 A peer-reviewed study from Dr. Jack Turban
et al in June 2021 found that among adults who detransition or retransition, 82.5% reported atleast one external driving factor including family and social stigma. 7 Instead of issuing blanketbans on gender-affirming care because some TGD people may detransition or retransition, we
need fewer invasive laws and policies that further entrench social and cultural stigma about
TGD people and identities and more support and resources for those who detransition orretransition.
Further, AG Bailey’s emergency regulation incorrectly cites “one scientific study” thatclaims an exponential increase in individuals identifying as transgender because of “socialfactors.” WPATH is unaware of any scientific study of this nature. Likely, however, the AG’s
office is referring to a 2018 report by Lisa Littman based upon parent observations and2

Risk of Pseudotumor Cerebri Added to Labeling for Gonadotropin-Releasing Hormone Agonists. Foodand Drug Administration (FDA), 1 July 2022, https://www.fda.gov/media/159663/download.
3“Pseudotumor Cerebri (Idiopathic Intracranial Hypertension) - Symptoms and Causes.” Mayo Clinic,
https://www.mayoclinic.org/diseases-conditions/pseudotumor-cerebri/symptoms-causes/syc-20354031.
Accessed 20 Mar. 2023.
4
Risk of Pseudotumor Cerebri Added to Labeling for Gonadotropin-Releasing Hormone Agonists. Foodand Drug Administration (FDA), 1 July 2022, https://www.fda.gov/media/159663/download.
5“Updated recommendations for hormone therapy for gender dysphoria in young people.”
Socialstyrelsen, 22 Feb. 2022, https://www.socialstyrelsen.se/omsocialstyrelsen/pressrum/press/uppdaterade-rekommendationer-for-hormonbehandling-vid-konsdysforihos-unga/.
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Kristina R. Olson, PhD, et al. “Gender Identity 5 Years After Social Transition.” Pediatrics, vol. 150, no.
2, Aug. 2022, https://doi.org/10.1542/peds.2021-056082.
7Turban, Jack L., et al. “Factors Leading to ‘Detransition’ Among Transgender and Gender DiversePeople in the United States: A Mixed-Methods Analysis.” LGBT Health, vol. 8, no. 4, 2021, pp. 273–80.
PubMed, https://doi.org/10.1089/lgbt.2020.0437.

2perceptions of their TGD child, adolescent, or young adult. 8 At no point during this process did
Littman interview, survey, or evaluate any TGD people themselves and in 2019, she issued acorrection to the report stating that,“Rapid-onset gender dysphoria (ROGD) is not a formal mental
health diagnosis at this time. This report did not collect data fromthe adolescents and young adults (AYAs) or clinicians andtherefore does not validate the phenomenon.”With this, Littman effectively disproves her own initial report. AG Bailey has used
outdated information from a report that was later challenged by the reports’ author, yet AG
Bailey’s inaccurate information remains in the emergency regulation.
Finally, AG Bailey’s citation about a study from the Endocrine Society and the rates ofgender incongruence in TGD children is also cherry-picked, this time from the 2017 Endocrine
Society Guidelines referencing Dr. Peggy Cohen-Kettenis’ data that only evaluated gendernonconforming children who were not necessarily transgender. 9 This claim from AG Bailey istherefore not only factually inaccurate but unrepresentative of those who would be affected bythis emergency regulation. More accurate data about persistence of gender identity for TGD
youth can be found in Dr. Olson’s peer-reviewed study which, as noted above, reports that
97.5% of TGD youth continue to identify as transgender or nonbinary 5 years after their initialsocial transition. 10 Further, a January 2023 longitudinal study from Dr. Diane Chen published in
the New England Journal of Medicine shows an increase in positive affect and life satisfaction
and a decrease in depression and anxiety for TGD youth after 2 years of hormones. 11
The emergency regulation issued by Missouri Attorney General Andrew Bailey is based
upon manipulated statistics, flawed reports, and incomplete data, and prevents the provision of
medically necessary care. Medical decisions must remain between providers and patients andtheir families. Consistent with earlier statements, WPATH and USPATH condemn any
legislative actions to restrict or prohibit access to gender-affirming health care.
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Littman, Lisa. “Parent Reports of Adolescents and Young Adults Perceived to Show Signs of a Rapid
Onset of Gender Dysphoria.” PLOS ONE, vol. 13, no. 8, Aug. 2018, p. e0202330. PLoS Journals,
https://doi.org/10.1371/journal.pone.0202330.
9Hembree, Wylie C. “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: AnEndocrine Society* Clinical Practice Guideline.” The Journal of Clinical Endocrinology & Metabolism, vol.
102, no. 11, Nov. 2017, pp. 3869–903, https://doi.org/10.1210/jc.2017-01658.
10
Kristina R. Olson, PhD. “Gender Identity 5 Years After Social Transition.” Pediatrics, vol. 150, no. 2,Aug. 2022, https://doi.org/10.1542/peds.2021-056082.
11
Chen, Diane, et al. “Psychosocial Functioning in Transgender Youth after 2 Years of Hormones.” New
England Journal of Medicine, vol. 388, no. 3, Jan. 2023, pp. 240–50. DOI.org (Crossref),https://doi.org/10.1056/NEJMoa2206297.

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