Category: Research quality
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NHS gender clinics do not meet quality assurance standards.
An operational and delivery review1 of adult gender clinics in England found that clinics lacked patient outcome data, had limited data reporting of inconsistent quality, and had minimal clinical audit. These failings put the clinics outside standard NHS quality assurance expectations.
These clinics also showed no signs of responding to the changing demographics of their referrals. Clinics made little effort to respond to the needs of this changing cohort, which was younger and more female than had previously been the case.
Some clinics reportedly carried out little or no knowledge-sharing or quality improvement work. Senior clinical leadership also steered some clinicians away from appropriate clinical curiosity, limiting opportunities to improve patient outcomes. In addition, many clinics were not well overseen by their local trust boards, nor by NHS England.
- Levy D, Operational and delivery review of NHS adult gender dysphoria clinics in England. https://www.england.nhs.uk/publication/operational-and-delivery-review-of-nhs-adult-gender-dysphoria-clinics-in-england/ ↩︎
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Psychological effects of puberty blockers on young people may be worse than placebo.
An analysis1 comparing psychological effects of puberty blockers on teenagers with gender dysphoria with existing research on placebo effects for various mental health conditions found that placebo effects appeared to be at least as strong as the effect of puberty blockers, if not stronger.
- https://sex-matters.org/wp-content/uploads/2022/12/Teenagers-medication-vs-placebo.pdf ↩︎
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Depression symptoms got worse in children taking puberty blockers.
In a study1 of 94 children with gender dysphoria, aged 8-16 and beginning to take puberty blockers, depression symptoms were more likely to get worse than to improve over two years of treatment. Scores on the Beck Depression Inventory (BDI-Y) went from 72% average, 10% mildly elevated, 10% moderately elevated, and 8% severely elevated at baseline to 75% average, 7% mildly elevated, 14% moderately elevated, and 9% severely elevated after 24 months.
This study was conducted from 2016 to 2021 by Dr. Johanna Olson-Kennedy. In 2024, the New York Times reported2 Dr. Olson-Kennedy saying that publication of this research had been delayed because she feared that research showing that puberty blockers did not improve patients’ mental health would be “weaponized” against the use of puberty blockers by opponents of the practice. The report appeared as a pre-print, not peer-reviewed, in May 2025.
- Johanna Olson-Kennedy, Liyuan Wang, Carolyn F. Wong, Diane Chen, Diane Ehrensaft, Marco A. Hidalgo, Amy C. Tishelman, Yee-Ming Chan, Robert Garofalo, Asa E. Radix, Stephen M. Rosenthal, Emotional Health of Transgender Youth 24 Months After Initiating Gender-Affirming Hormone Therapy, Journal of Adolescent Health, Volume 77, Issue 1, 2025, Pages 41-50, ISSN 1054-139X, https://doi.org/10.1016/j.jadohealth.2024.11.014. ↩︎
- https://www.nytimes.com/2024/10/23/science/puberty-blockers-olson-kennedy.html
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A systematic review demonstrated flaws in measurement of regret rates across all studies.
A systematic review of regret rates across 27 studies1 showed that every study had insufficient follow-up time and/or high drop-out rates, which seriously compromise the reliability of the data on regret rates. The review’s authors describe this as a “moderate to high” risk of bias. They also note that definitions of regret and methods of measuring it are variable, and that participants may feel shame or fear of judgement and so conceal their regret. These factors combine to make the regret rate reported in the study unreliable.
- Bustos VP, Bustos SS, Mascaro A, Del Corral G, Forte AJ, Ciudad P, Kim EA, Langstein HN, Manrique OJ. Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence. Plastic and Reconstruction Surgery Global Open. 2021 Mar 19;9(3):e3477. doi: 10.1097/GOX.0000000000003477. Erratum in: Plast Reconstr Surg Glob Open. 2022 Apr 28;10(4):e4340. doi: 10.1097/GOX.0000000000004340. PMID: 33968550; PMCID: PMC8099405. ↩︎
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High drop-out rates mean reported detransition rates are misleading.
An ethics-focused meta-study of psychosocial outcomes of “gender reassigment”1 found that 20-60% of participants were lost to follow up. Remaining research participants were more likely to report satisfaction with interventions, so reported rates of regret/desistance/detransition in such studies may be highly misleading.
- D’Angelo R. Psychiatry’s ethical involvement in gender-affirming care. Australasian Psychiatry. 2018 Oct;26(5):460-463. doi: 10.1177/1039856218775216. Epub 2018 May 21. PMID: 29783857.
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- D’Angelo R. Psychiatry’s ethical involvement in gender-affirming care. Australasian Psychiatry. 2018 Oct;26(5):460-463. doi: 10.1177/1039856218775216. Epub 2018 May 21. PMID: 29783857.
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36% of patients at Amsterdam gender clinic were lost to follow up.
In a study of all patients at a clinic treating 95% of all trans-identified people in the Netherlands1, 36% of all patients were lost to follow up. This may make reported rates of regret or detransition highly unreliable2. Rates of “regret” in the study itself may be compromised by a definition of “true regret” marked by beginning hormone therapy reflecting the patient’s sex (e.g. testosterone therapy for detransitioning “trans women” or estrogen therapy for detransitioning “trans men.”) The study also notes that some of those experiencing “true regret” had thought that transition would be a “solution” for their homosexuality. Regret was expressed between 46 and 271 months after beginning cross-sex hormone treatment. This may suggest there is a long tail of such regret still to come, even from those who began treatment more than twenty years ago.
- Wiepjes CM, Nota NM, de Blok CJM, Klaver M, de Vries ALC, Wensing-Kruger SA, de Jongh RT, Bouman MB, Steensma TD, Cohen-Kettenis P, Gooren LJG, Kreukels BPC, den Heijer M. The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets. J Sex Med. 2018 Apr;15(4):582-590. doi: 10.1016/j.jsxm.2018.01.016. Epub 2018 Feb 17. PMID: 29463477 ↩︎
- https://catalogofbias.org/biases/attrition-bias/ ↩︎
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There is no high-quality evidence supporting the use of puberty blockers for gender distress
A 2024 systematic review by Taylor et al. at the University of York1 was commissioned by the Cass Review to rigorously assess the safety and effectiveness of puberty suppression in adolescents with gender dysphoria. Analyzing studies up to April 2022, the review included 11 cohort, 8 cross-sectional, and 31 pre-post studies, but only one cross-sectional study met high-quality standards. The meta-analysis of moderate to high-quality studies showed limited and inconsistent evidence of benefits in areas like gender dysphoria, mental health, and body satisfaction.
This finding aligns with the previous 2020 review by the British National Institute for Clinical Excellence (NICE) on puberty blockers2, which described the supporting evidence as “very low” quality. The review noted minimal changes in key outcomes like gender dysphoria, mental health, and quality of life due to small, uncontrolled observational studies. Furthermore, a 2024 review from Germany by Zepf et al.3, adhering to NICE criteria, confirmed the absence of new studies on puberty blockers for gender dysphoria since the NICE review.
- Taylor, J., Mitchell, A., Hall, R., Heathcote, C., Langton, T., Fraser, L., & Hewitt, C. E. (2024). Interventions to suppress puberty in adolescents experiencing gender dysphoria or incongruence: a systematic review. Archives of disease in childhood, archdischild-2023-326669. [Link] ↩︎
- National Institute for Health and Care Excellence (2021). Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria. National Institute for Health and Care Excellence (NICE); NHS England; NHS Improvement. [Link] ↩︎
- Zepf, F. D., König, L., Kaiser, A., Ligges, C., Ligges, M., Roessner, V., … & Holtmann, M. (2024). Beyond NICE: Aktualisierte systematische Übersicht zur Evidenzlage der Pubertätsblockade und Hormongabe bei Minderjährigen mit Geschlechtsdysphorie. Zeitschrift für Kinder-und Jugendpsychiatrie und Psychotherapie. [Link] ↩︎
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It is not true that 1.7% of the population is ‘born between the sexes’. The proportion of people with DSDs (‘intersex’ conditions) is 0.018%
Conditions in which chromosomal sex is inconsistent with phenotypic sex, or in which the phenotype is not classifiable as either male or female, occur in 0.018% of the population1.
The claim that 1.7% of the population is ‘intersex’2 includes conditions which most clinicians do not recognize as intersex, and is often wrongly used to back up the ideological assertion that ‘sex is a spectrum’, or that biological sex is not dimorphic.
The philosopher Kathleen Stock points out that she would be considered as “intersex” under Fausto-Sterling’s “preposterously over-demanding conditions on sex category membership”, as she lost an ovary in early adulthood3, which would count as “intersex” according to Fausto-Sterling.
- Sax, L. (2002). How common is intersex? a response to Anne Fausto-Sterling. J Sex Res. 39 (3): 174-8. [Link] ↩︎
- Fausto-Sterling, A. (2000). Sexing the Body: Gender Politics and the Construction of Sexuality. New York: Basic Books. [Link] ↩︎
- Stock, K. (2021). Material Girls. Little, Brown Book Group: p.56 [Link] ↩︎
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There is very little evidence on the number of people who have detransitioned
In a study1 of 100 detransitioners, only 24% of respondents informed their clinicians that they had detransitioned. The vast majority made no attempt to contact their clinics.
Not only does this mean that we have no way of ascertaining how many people detransition, it also potentially impact clinics’ assessments of patient satisfaction.
One paper2 claimed that the detransition rate was 13.1%. However, this research relies on data from the U.S. Transgender Survey, which was conducted via community outreach organizations, and may therefore have excluded detransitioners who were no longer in touch with any such organizations. Only people who still identified as members of the trans community were included:
The 2015 U.S. Transgender Survey (USTS) was conducted by the National Center for Transgender Equality (NCTE) to examine the experiences of transgender adults in the United States.
By contrast, the study by Lisa Littman sought respondents from a political and ideological variety of sources.
In a recent retrospective case-note review3, performed as a service evaluation over twelve months, 6.9% of participants met the case definition of detransitioning, yet 21.7% disengaged from the study.
In general, detransitioners remain an underserved population in healthcare, with far more research required to understand their needs4.
- Littman, L. (2021). Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners. Arch Sex Behav. [Link] ↩︎
- Turban, J.L., Loo, S.S., Almazan, A.N., & Keuroghlian, A.S. (2021). Factors Leading to “Detransition” Among Transgender and Gender Diverse People in the United States: A Mixed-Methods Analysis. LGBT health 8(4): 273-280. [Link] ↩︎
- Hall, R., Mitchell, L., & Sachdeva, J. (2021). Access to care and frequency of detransition among a cohort discharged by a UK national adult gender identity clinic: Retrospective case-note review. BJPsych Open 7(6): E184. [Link] ↩︎
- Expósito-Campos, P. (2021). A Typology of Gender Detransition and Its Implications for Healthcare Providers. Journal of Sex & Marital Therapy 47 (3): 270-280. [Link] ↩︎
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While long-term study is lacking, one case study suggests that tucking can affect fertility
In a case study1 of one transwoman, tucking resulted in oligospermia – an abnormally low sperm count – affecting fertility. Elevation of the testes because of tucking may contribute to heat stress and consequent impairment of spermatogenesis.
After cessation of tucking and the provision of a new sperm sample, the sperm count in the patient was improved, and the semen had increased opacification.
A further study2 found that tucking could create a suboptimal environment for spermatogenesis.
- Trussler, J. T., & Carrasquillo, R. J. (2020). Cryptozoospermia Associated With Genital Tucking Behavior in a Transwoman. Reviews in urology, 22 (4), 170–173. [Link] ↩︎
- Debarbo, C.J.M. (2020). Rare cause of testicular torsion in a transwoman: A case report. Urology Case Reports 33. [Link] ↩︎
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There is little evidence that medical transition decreases suicidality
When it comes to gender dysphoric children, there is little evidence that medical transition decreases suicide rates. There is little evidence to assert that puberty blockers are necessary to prevent suicide1.
After sex reassignment surgery, one study showed that adult transsexual clients were 4.9 times more likely to have made a suicide attempt and 19.1 times more likely to have died from suicide, after adjusting for prior psychiatric comorbidity2. Similarly, an Australian paper3 notes that many patients have poor outcomes, which puts them at risk of suicide.
A prominent study4 claiming that medical transition alleviated suicidality had to be corrected5, to clarify that it proved “no advantage of surgery” in this regard.
A long-term Swedish study6 finds that post-operative transgender people have “considerably higher risks” for suicidal behavior.
Similarly, a study in the European Journal of Endocrinology7 demonstrates that suicide rates among transgender male-to-females were 51% higher than the general population.
- Biggs, M. (2020). Puberty Blockers and Suicidality in Adolescents Suffering from Gender Dysphoria. Archives of Sexual Behavior (49): 2227–2229. [Link] ↩︎
- Zucker, K.J., Lawrence, A.A., Kreukels, B.P. (2016). Gender Dysphoria in Adults. Annu Rev Clin Psychol. 12: 217-47. [Link] ↩︎
- D’Angelo, R. (2018). Psychiatry’s ethical involvement in gender-affirming care. Australasian Psychiatry 26 (5): 460-463. [Link] ↩︎
- Bränström, R. & Pachankis, J. E. (2019). Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study. American Journal of Psychiatry 177 (8): 727-734. [Link] ↩︎
- American Journal of Psychiatry (2020). Correction to Bränström and Pachankis. Published online: 1 August 2020. [Link] ↩︎
- Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. L. V., Långström, N., & Landén, M. (2011). ‘Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study in Sweden’. PLoS ONE, 6(2). [Link] ↩︎
- Asscheman, H., Giltay, E. J., Megens, J. A. J., de Ronde, W., van Trotsenburg, M. A. A. & Gooren, L. J. G. (2011). A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. European Journal of Endocrinology 164 (4). [Link] ↩︎
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Suicide rarely has one cause: it is difficult for statistical studies on suicide to extricate gender dysphoria from other factors
A Swedish study1 points out that it is “difficult to distinguish one [gender dysphoria] from the other [mental health conditions] with regard to suicide risk.”
A 2019 study2 finds that “adolescents referred for gender dysphoria show higher rates of suicidality when compared to non-referred adolescents, but are much more similar to referred adolescents (presumably, the vast majority were cisgender) in general.”
- Swedish National Board of Health and Welfare (2020). Utvecklingen av diagnosen könsdysfori: Förekomst, samtidiga psykiatriska diagnoser och dödlighet i suicid. Socialstyrelsen. [Link] ↩︎
- Zucker, K. J. (2019). Adolescents with Gender Dysphoria: Reflections on Some Contemporary Clinical and Research Issues. Archives of Sexual Behavior 48 (5). [Link] ↩︎
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There is no high quality evidence to suggest that the overall attempted suicide rate of transgender youth is 41%
The frequently repeated claim that 41% of 6,450 transgender respondents said they had attempted suicide at some point in their lives1 is taken from the National Transgender Discrimination Survey2.
However, a 2021 paper3 notes that the participants were recruited through transgender advocacy organizations and subjects were asked to “pledge” to promote the survey among friends and family. This recruiting method yielded a large but highly skewed sample. By targeting transgender advocacy groups, the survey underrepresented the experiences of transgender individuals who are not politically engaged. Also, a very high number of the survey participants (nearly 40%) had not transitioned medically or socially at the time of the survey, and a significant number reported no intention to transition in the future.
A 2016 article4 analyzes the power of this 41% statistic, investigating how it has affected conversations about the injustices transgender people face and the importance of family and societal acceptance.
- Turban, J. L., Beckwith, N., Reisner, S. L., & Keuroghlian, A. S. (2020). Association between recalled exposure to gender identity conversion efforts and psychological distress and suicide attempts among transgender adults. JAMA Psychiatry 77 (1): 68-76. [Link] ↩︎
- Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Keisling, M. (2011). Injustice at every turn: A report of the national transgender discrimination survey. National Gay and Lesbian Task Force; National Center for Transgender Equality. [Link] ↩︎
- D’Angelo, R., Syrulnik, E., Ayad, S., Marchiano, L., Kenny, D.T. & Clarke, P. (2021). One Size Does Not Fit All: In Support of Psychotherapy for Gender Dysphoria. Arch Sex Behav 50: 7-16. [Link] ↩︎
- Tanis, J. (2016). The power of 41%: A glimpse into the life of a statistic. Am J Orthopsychiatry, 86 (4): 373-7. [Link] ↩︎
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Studies on gender dysphoric young people often suffer from high rates of loss to follow-up – which could skew transition satisfaction rates
In one study1 of 77 pre-teen participants, 30% were lost to follow up by their teenage years: either they did not respond to the recruiting letter, or were not traceable. In another study2, as many as 75% of participants were lost to follow up.
An excellent précis of this problem can be found in a 2018 paper3, which gives further detail:
Smith et al. report that sex reassignment is effective, based on a study of 162 adults who had undergone SRS. They were able to obtain follow-up data from only 126 (78%) of subjects because a significant number were “untraceable” or had moved abroad.
De Cuypere et al. report that sex reassignment surgery is an effective treatment for transsexuals. Of 107 patients who had undergone SRS between 1986 and 2001, 30 (28%) could not be contacted and 15 (14%) refused to participate.
Johannson et al. reported good outcomes for SRS. Of 60 patients who had undergone SRS, 42 (70%) agreed to participate in the follow up research. Of the non-participants, 1 had died of complications of SRS, 8 could not be contacted and 9 refused to participate.
Salvador et al. reported that SRS has a positive effect on psychosocial functioning. Only 55 of the 69 patients (80%) could be contacted as 17 were lost to follow-up
Van de Grift et al. reported 94–96% of patients are satisfied with SRS and have good quality of life. A total of 546 patients with Gender Dysphoria who had applied for SRS at clinics in Amsterdam, Hamburg and Ghent were contacted to complete an online survey. Only 201 (37%) responded and completed the survey.
A good example of how this phenomenon can affect satisfaction and regret statistics comes from a 2018 paper4, which is often cited as proof of low regret rates. The loss to follow up rate in this paper is 36%. The authors also state:
In addition, in our population the average time to regret was 130 months, so it might be too early to examine regret rates in people who started with HT [hormonal treatment] in the past 10 years.
- Wallien, M.S. & Cohen-Kettenis P.T. (2008) Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry 47 (12): 1413-23. [Link] ↩︎
- Rauchfleisch, U., Barth, D. & Battegay, R. (1998). Resultate einer Langzeitkatamnese von Transsexuellen. Der Nervenzart 69: 799-805. [Link] ↩︎
- D’Angelo, R. (2018). Psychiatry’s ethical involvement in gender-affirming care. Australasian Psychiatry 26 (5): 460-463. [Link] ↩︎
- Wiepjes, C.M., Nota, N.M., de Blok, C.J.M., Klaver, M., de Vries, A.L.C., Wensing-Kruger, S.A., de Jongh, R.T., Bouman, M.B., Steensma, T.D., Cohen-Kettenis, P., Gooren, L.J.G., Kreukels, B.P.C. & den Heijer, M. (2018). The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets. Journal of Sexual Medicine 15 (4). [Link] ↩︎
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There is limited evidence that medical transition leads to positive outcomes
A number of different studies have noted the paucity of good quality evidence for transition.
An Australian paper1 states that most available evidence indicating positive outcomes for gender reassignment is of poor quality.
A German study2 “found insufficient evidence to determine the efficacy or safety of hormonal treatment approaches for transgender women in transition”, adding that “[t]his lack of studies shows a gap between current clinical practice and clinical research.”
A British review3 conducted by the National Institute for Health and Care Excellence (NICE) graded certainty of evidence for puberty blocker use as “very low” in every category, including impact on gender dysphoria, mental health, body image, global functioning, psychosocial functioning, cognitive functioning, bone density and adverse effects.
A chapter4 in an edited volume details the low evidence base for treatment pathways employed at the UK’s Gender Identity Development Service, demonstrating how negative evidence was “ignored or suppressed”.
Finally, a systematic review5 commissioned by the World Professional Association for Transgender Health (WPATH) to “systematically review the effect of gender-affirming hormone therapy on psychological outcomes among transgender people” noted that, in some areas, there was low quality or insufficient evidence.
- D’Angelo, R. (2018). Psychiatry’s ethical involvement in gender-affirming care. Australasian Psychiatry 26 (5): 460-463. [Link] ↩︎
- Haupt, C., Henke, M., Kutschmar, A., Hauser, B., Baldinger, S., Saenz, S.R. & Schreiber, G. (2020). Antiandrogen or estradiol treatment or both during hormone therapy in transitioning transgender women. Cochrane Database of Systematic Reviews 11. [Link] ↩︎
- National Institute for Health and Care Excellence (2021). Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria. National Institute for Health and Care Excellence (NICE); NHS England; NHS Improvement. [Link] ↩︎
- Biggs, M. (2019). The Tavistock’s Experiment with Puberty Blockers. In: Moore, M. & Brunskell-Evans, H. (eds.). Inventing Transgender Children and Young People. Cambridge Scholars Publishing. [Link] ↩︎
- Baker, K.E., Wilson, L.M., Sharma, R., Dukhanin, V., McArthur, K. & Robinson, K.A. (2021) Hormone Therapy, Mental Health, and Quality of Life Among Transgender People: A Systematic Review. Journal of the Endocrine Society 5 (4). [Link] ↩︎