2022 Florida Department of Health anti-trans report

On April 20, 2022, the Florida Department of Health released a report created as a pretext for banning trans healthcare for minors in Florida.

Background

Florida has long been one of the most hostile US states regarding the rights of trans and gender diverse people. Using slogans like “working together to protect our children” and “let kids be kids,” the state undertook an effort to eliminate gender affirming care for minors.

Funding recipients

According to CBS News Miami:

The state agency in July issued a nearly $1 million contract for legal services and costs in the litigation.

According to state records, the DeSantis administration also was willing to pay up to $322,323 for “expert witness” services from seven doctors and researchers who contributed to an AHCA report or appeared at a public hearing on the issue. The researchers received a total of $42,621.83 through purchase orders issued between May and August last year.

Many of the state’s experts are affiliated with religious organizations or have endorsed “conversion therapy,” which seeks to change sexual or gender identities of LGBTQ people. The practice has been discredited by major parts of the medical community.

Andre Van Mol: $15,104.55 (~$70,000 approved)
Quentin Van Meter: $12,417.28
James Cantor: $9,600
Patrick Lappert: $34,800 purchase order
Miriam Grossman: $5,500
Romina Brignardello-Petersen: $34,650 purchase order
Gerard Kevin Donovan: $34,650 purchase order
Holtzman Vogel Baran Torchinsky & Josefiak, PLLC: $950,000 contract

Guidance

On April 20, 2022, the Florida Department of Health issued guidance related to gender affirming care for minors. The Secretary of the Florida Agency for Health Care Administration (AHCA) requested that Florida’s Medicaid program review “whether treatments are consistent with widely accepted professional medical standards.” AHCA commissioned five reports as a pretext for banning coverage of gender affirming care. The authors are:

The June 2, 2022 AHCA report found that “several services for the treatment of gender dysphoria – i.e., sex reassignment surgery, cross-sex hormones, and puberty blockers – are not consistent with widely accepted professional medical standards and are experimental and investigational with the potential for harmful long term affects.”

Summary

On April 20, 2022, Florida Department of Health release a guidance titled “Treatment of Gender Dysphoria for Children and Adolescents.” It states:

The Florida Department of Health wants to clarify evidence recently cited on a fact sheet [HHS 2023] released by the US Department of Health and Human Services and provide guidance on treating gender dysphoria for children and adolescents.

Systematic reviews on hormonal treatment for young people show a trend of low-quality evidence [Hruz 2019], small sample sizes, and medium to high risk of bias. A paper published in the International Review of Psychiatry [Ristori & Steensma 2015] states that 80% of those seeking clinical care will lose their desire to identify with the nonbirth sex. One review concludes [Chew, Anderson, Williams, May & Pang 2018] that “hormonal treatments for transgender adolescents can achieve their intended physical effects, but evidence regarding their psychosocial and cognitive impact is generally lacking.”

According to the Merck Manual, “gender dysphoria is characterized by a strong, persistent crossgender identification associated with anxiety, depression, irritability, and often a wish to live as a gender different from the one associated with the sex assigned at birth.”

Due to the lack of conclusive evidence, and the potential for long-term, irreversible effects, the Department’s guidelines are as follows:

Social gender transition should not be a treatment option for children or adolescents. [link: Sievert, Schweizer, Barkman, Fahrenkrug & becker-Hebly 2020]

Anyone under 18 should not be prescribed puberty blockers or hormone therapy.

links:

prescribed: Carmichael, Butler, Masic, Cole, De Stavola, Davidson, Skageberg, Khadr, & Viner (2021)

puberty: Goddings, Mills, Clasen, Giedd, Viner, Blakemore (2014)

blockers: Clayton, Malone, Clarke, Mason, D’Angelo (2021)

hormone: Kaltiala, Heino, Työläjärvi, Suomalainen (2019)

therapy: Haupt, Henke, Kutschmar, Hauser, Baldinger, Saenz, Schreiber (2020)

Gender reassignment surgery should not be a treatment option for children or adolescents.

Based on the currently available evidence, “encouraging mastectomy, ovariectomy,
uterine extirpation, penile disablement, tracheal shave, the prescription of hormones
which are out of line with the genetic make-up of the child, or puberty blockers, are all
clinical practices which run an unacceptably high risk of doing harm.”

links:

Gender reassignment surgery: SBU report – Ludvigsson, Kriström, Landén, Rydelius, Kihlbom, Sandman, Msghina, Wæhre, and Elfving (2019)

not be a treatment option: COHERE Finland (2020) https://palveluvalikoima.fi/documents/1237350/22895008/Summary_minors_en+(1).pdf/

currently available evidence: Schwartz (2021)

Children and adolescents should be provided social support by peers and family and seek
counseling from a licensed provider.

These guidelines do not apply to procedures or treatments for children or adolescents born with a
genetically or biochemically verifiable disorder of sex development (DSD) [Witchel 2019]. These disorders include, but
are not limited to, 46, XX DSD; 46, XY DSD; sex chromosome DSDs; XX or XY sex reversal; and
ovotesticular disorder.

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.
Parents are encouraged to reach out to their child’s health care provider for mor

age requirement for surgical and non-surgical treatment: A53793 – Billing and Coding: Gender Reassignment Services for Gender Dysphoria http://cms.gov/medicare-coverage-database/view/article.aspx?articleid=53793 [archive]

recommendations: God vård av barn och ungdomar med könsdysfori (2021) https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/kunskapsstod/2015-4-6.pdf [archive]

Sweden: SBU report – Ludvigsson, Kriström, Landén, Rydelius, Kihlbom, Sandman, Msghina, Wæhre, and Elfving (2019)

Finland: COHERE Finland (2020) https://palveluvalikoima.fi/documents/1237350/22895008/Summary_minors_en+(1).pdf/

the United Kingdom: Cass (2022) https://webarchive.nationalarchives.gov.uk/ukgwa/20250310143642/https://cass.independent-review.uk/

France: French National Academy of Medicine (2022) https://www.academie-medecine.fr/la-medecine-face-a-la-transidentite-de-genre-chez-les-enfants-et-les-adolescents/

Press release

An FDOH press release stated:

Tallahassee, Fla. — Today, the Florida Department of Health released guidance regarding the treatment of gender dysphoria for children and adolescents. This guidance uses the most up-to-date scientific data available, and it prioritizes the overall health and well-being of Florida’s children and adolescents. The Department’s guidance is available here.

“The federal government’s medical establishment releasing guidance failing at the most basic level of academic rigor shows that this was never about health care,” said State Surgeon General Joseph Ladapo. “It was about injecting political ideology into the health of our children. Children experiencing gender dysphoria should be supported by family and seek counseling, not pushed into an irreversible decision before they reach 18.”

Countries such as Sweden, Finland, France, and the United Kingdom are currently reviewing, reevaluating, stopping, or advising caution on the treatment of gender dysphoria in children and adolescents.

The Department crafted this guidance using published and peer-reviewed data that calls into question the motives of the federal HHS. Guidance of this magnitude requires a full, diligent understanding of the scientific evidence.

The current evidence does not support the use of puberty blockers, hormone treatments, or surgical procedures for children and adolescents, considering:

80% of those seeking clinical care will lose their desire to identify with the non-birth sex,
the importance of puberty to brain development, with the pre-frontal cortex (which is responsible for executive functions, such as decision making) continuing to develop until approximately 25 years of age,
and the potentially irreversible consequences such as cardiovascular disease, osteoporosis, infertility, increased cancer risk, and thrombosis.

Alongside the guidance released today, the Department released a fact check that details the claims made by HHS, available here.

Responses

On July 8, 2022, Yale University pediatrician Meredithe McNamara and colleagues released “A Critical Review of the June 2022 Florida Medicaid Report on the Medical Treatment of Gender Dysphoria.” In it, they discuss the undisclosed conflict of interest:

The linchpin of the June 2 Report is the analysis by Brignardello-Petersen and Wiercioch (the “BPW document”), provided as Attachment C, which purports to be a comprehensive review of the scientific literature on medical treatment for gender dysphoria but, in fact, is extremely narrow in scope and so flawed in its analysis that it merits no scientific weight.

Romina Brignardello-Petersen is one of two authors of the document provided as Attachment C to the June 2 Report. Although Brignardello-Petersen claims to have no research interests in medical care for transgender youth,25 she has conducted research for the Society for Evidence-Based Gender Medicine (“SEGM”). 26 Although SEGM claims to be an international medical society, it is actually an activist group that opposes standard medical care for gender dysphoria. The SEGM has no publications or conferences and seems to consist solely of a website created by a small group of people with limited or no scientific credentials or clinical experience. The site presents a cherry-picked collection of studies and narrative content that is full of scientific errors. 27

26. Like the van Meter and Cantor attachments, the BPW document provides no express statement of conflicts of interest. The BPW document does offer a statement of “credentials and expertise,” in which she declares that “her research interests are not in this area,” meaning apparently research on medical care for gender dysphoria.

27. For one example of the purported research that Brignardello-Petersen apparently assisted in, see Alison Clayton et al., Commentary: the Signal and the Noise – Questioning the Benefits of Puberty Blockers for Youth with Gender Dysphoria – A Commentary on Rew et al. (2021), Child and Adolescent Mental Health, Dec. 22, 2021, at https://acamh.onlinelibrary.wiley.com/doi/10.1111/camh.12533. In the “Acknowledgements” section, the authors state, “We would also like to thank the Society for Evidence-based Gender Medicine (SEGM) for providing access to several experts who helped shape this commentary and ensure its accuracy. Specifically, we would like to thank Dr. Romina Brignardello Petersen [sic] for contributing her methodological expertise.”

References

PFLAG (September 2023). Annotated Bibliography of Point-by-Point Rebuttals of Anti-Transgender Disinformation. https://pflag.org/wp-content/uploads/2023/09/Annotated-Bibliography-of-Point-by-Point-Rebuttals-of-Anti-Transgender-Disinformation.pdf

Mahoney, Emily L.; Ellenbogen, Romy (August 2, 2023). Florida deviated from standard practices for key report regarding transgender care. Miami Herald https://www.miamiherald.com/news/health-care/article277853063.html

McNamara, M., Abdul-Latif, H., Boulware, S. D., Kamody, R., Kuper, L. E., Olezeski, C. L., Szilagyi, N., & Alstott, A. (2023). Combating Scientific Disinformation on Gender-Affirming Care. Pediatrics, 152(3). https://doi.org/10.1542/peds.2022-060943

Staff report (January 23, 2023). Florida runs up tab in Medicaid transgender case. CBS News Miami https://www.cbsnews.com/miami/news/florida-runs-up-tab-in-medicaid-transgender-case/

Staff (August 5, 2022). Advocates Urge Florida Board of Medicine to Reject Anti-Transgender Health Care Guidance. Lambda Legal https://legacy.lambdalegal.org/blog/fl_20220805_advocates-urge-fl-board-of-medicine-to-reject-anti-transgender-health-care-guidance

McNamara et al (July 8, 2022). A Critical Review of the June 2022 Florida Medicaid Report on the Medical Treatment of
Gender Dysphoria. https://files-profile.medicine.yale.edu/documents/c11e1419-a122-4b2f-87a8-cc4c9fbf57a4

Stagg (June 2, 2022). Equality Florida Responds to AHCA Report on Treatment of Gender Dysphoria, Equality Florida https://eqfl.org/ahca-report

Jones, Zinnia (May 4, 2022). Florida’s targeted healthcare guide for trans youth is an error-riddled mess. Xtra* https://xtramagazine.com/health/florida-trans-guidelines-222392

Jones, Zinnia (Apr 28, 2022). Florida Department of Health Guidance Against Trans Youth Healthcare Contains False Statements and Misrepresentations and Should Not Be Used by Anyone. Medium https://zinniajones.medium.com/florida-department-of-health-guidance-against-trans-youth-healthcare-contains-false-statements-594a2cf96d9c

Florida Department of Health Communications (April 20, 2022). Florida Department of Health Releases Guidance on Treatment of Gender Dysphoria for Children and Adolescents. https://www.floridahealth.gov/newsroom/2022/04/20220420-gender-dysphoria-press-release.pr.html?utm_source=chatgpt.com

Florida Department of Health (April 20, 2022). Treatment of Gender Dysphoria for Children and Adolescents. https://www.floridahealth.gov/newsroom/2022/04/20220420-gender-dysphoria-guidance.pr.html