One evidence review of the literature on gender affirming care for youth. Two evidence reviews on gender affirming care for youth. Three evidence reviews on gender affirming care for youth! (Well, “evidence review” might be stretching it for two of these three.) So many reviews!
First we had the Cass Report out of the UK, then the HHS Report from the US government, and now a report out of Utah. Utah’s evidence review is a truly academic, well-designed review of the literature about taking care of trans youth. The others, as we and many others have said, lacked scientific rigor and showed clear political bias. (See the bottom of this page for links to articles discussing the HHS review and the Cass Report.)
The History of Utah’s Evidence Review
In 2023, Utah passed a youth care ban. This ban required that an evidence review be completed by November 2024.
They didn’t make that deadline, but they did publicly release a 1000-page report in May of 2025.
Get a copy! 1000 pages can be a lot, but most of it is data tables and the bibliography. This is a great resource to have around for looking up and citing studies about trans youth care.
The first download report link on the Utah State Legislature page is the review. The second download report link is a summary with recommendations.
TLDR: OVERALL CONCLUSIONS
We’ve included their words below, but here’s what they said translated out of science-speak:
After reviewing the research, experts agree that banning medical treatment for transgender young people isn’t supported by science. The evidence just doesn’t back up those bans or the fear that many people will regret getting care later. There are already really good medical guidelines available to help trained providers safely care for kids and teens who are appropriate for this kind of treatment.
AND
After spending a long time reading and studying the science, the experts came to some big conclusions. After spending a long time reading and studying the science, the experts came to some big conclusions. The research shows that medical treatments for transgender young people help with mental health, social well-being, and help their bodies look more like the gender they know themselves to be. The research also shows these treatments are safe. Things like bone strength, heart health, and other body changes stay in the normal ranges. Some small changes might happen, but they usually aren’t harmful, and young people stay healthy. Things like bone strength, heart health, and other body changes stay in the normal ranges. Some small changes might happen, but they usually aren’t harmful, and young people stay healthy.
FUCK YEAH!
Here is the original language:
Based on the reviewed evidence included in this report, it is our expert opinion that policies to prevent access to and use of GAHT for treatment of GD in pediatric patients cannot be justified based on the quantity or quality of medical science findings or concerns about potential regret in the future, and that high-quality guidelines are available to guide qualified providers in treating pediatric patients who meet diagnostic criteria.
and
…after having spent many months searching for, reading, and evaluating the available literature, it was impossible for us to avoid drawing some high-level conclusions. Namely, the consensus of the evidence supports that the treatments are effective in terms of mental health, psychosocial outcomes, and the induction of body changes consistent with the affirmed gender in pediatric GD patients. The evidence also supports that the treatments are safe in terms of changes to bone density, cardiovascular risk factors, metabolic changes, and cancer. With regards to these safety outcomes, reviewed studies show that any patient level changes are minimal, and that despite any small improvements or decrements in individual disease risk factors, the average patient’s values remain within the bounds of normal, non-pathological ranges for human populations.
Systematic Medical Evidence Review of Hormonal Transgender Treatment Report, Utah Department of Health and Human Services, pg 116
Want to skip all of the text and numbers and get a recap of the review by video? Here’s a tiktok from elevate_utah (we’re not associated, but we agree with their commentary!)
What Were The Objectives Of Utah’s Evidence Review?
The group was tasked with several questions:
1. On The Medicines Used in Gender Affirming Care
- What hormones and hormone blockers are used in gender affirming care of youth with gender dysphoria?
- Are they approved by the US Food and Drug Administration (FDA) for use in youth?
- What are the reasons for and reasons against using these hormones?
- What recognized off-label pediatric reasons to use these hormones and hormone blockers are there?
The Results:
- They identified 66 prescription drugs “that are used off label or recommended for off-label use” for gender dysphoria in the United States.
- There aren’t any FDA-approved medications SPECIFICALLY for gender dysphoria. (Requiring the use of medications with FDA-approval for gender dysphoria is an emerging ban tactic.)
- 24 of those medications DO HAVE an FDA-approved use for youth.
- 14 of these medications have a recognized off-label use for youth
- 6 of those for gender dysphoria.
- All 66 of those medications DO HAVE an FDA-approved use for adults. 37 of those have a recognized off-label use for adults with gender dysphoria.
What is Off-Label Use?
Off-Label Use is the use of a medication that has not gone through the official FDA-process to declare that a medication “treats this condition”. Many, many medicines are used off-label, and off-label uses are documented.
As TransVitae notes in the article New Study Validates Gender Affirming Care for Adolescents,
“off-label prescribing is common, legal, and medically accepted in pediatric care. In fact, the authors note that nearly 40% of all prescriptions for U.S. children are off-label, including many antibiotics, asthma medications, and psychiatric drugs. The only reason gender affirming care appears to be singled out is because of stigma, not science.”
2. On The Guidelines About Gender Affirming Care
- What recent guidelines on gender affirming care for youth are there?
- What recommendations about medications are made in those guidelines?
- What are the levels of evidence that support those recommendations?
- They identified 5 guidelines in their literature search.
- 4 passed review and were included in the evidence tables.
- WPATH (World Professional Association for Transgender Health 2022)
- Endocrine Society, 2017
- European Society for Sexual Medicine, 2020
- American College of Obstetricians and Gynecologists, 2022
What Did These Guidelines Recommend?
- Hormonal therapy should not start before puberty.
- Generally, hormonal therapy includes hormone blockers and hormones such as estradiol and testosterone.
- The guidelines generally agree that youth should meet eligibility criteria and not have any contraindications to treatment.
- Meet diagnostic criteria for gender incongruence.
- This incongruence is marked and sustained over time.
- The youth has the emotional and cognitive maturity to provide informed consent/assent for the treatment.
- Any mental health concerns that may interfere with the capacity to consent have been addressed.
- The youth knows about the impact of treatment on reproductive ability.
- The youth has reached Tanner stage 2.
How was the evidence for these recommendations graded?
- For treatment criteria: STRONG.
- That health care systems should provide medically necessary gender affirming care: STRONG.
- That hormonal suppression may begin after reaching Tanner Stage 2: STRONG.
- May begin sex hormone replacement therapy if in Tanner stage 2 or later (parental involvement is recommended unless not necessary): STRONG.
- GnRH analogs (blockers) are recommended when puberty suppression is indicated: STRONG.
3. On The Compilation of Systematic Reviews and Studies
- “What systematic reviews and meta-analyses, randomized controlled clinical trials, and observational studies address short- and long-term safety and efficacy outcomes of hormonal and hormone-blocking agents used for gender affirming care” in youth are available?
- What are the main and secondary findings of experimental, observational, and descriptive studies.
- What is the quality of the evidence?
38 Systematic Reviews were identified. 7 were used.
- 31 were given low-priority for inclusion in the data tables and were included in the biography only.
Of the 7 Systematic Reviews:
- 7 discussed psychosocial outcomes (“psychosocial” is all the factors that can impact a person’s ability to function and their overall physical and mental health – it can include housing, education, income, sleep quality, diet quality, family history, community supports, trauma, and risky and healthy behaviors, among others)
- 6 discussed body changes and bone health
- 5 discussed mental health
- 4 discussed cardiovascular health
134 English-language Clinical Studies were identified with a patient base of 28,000 youth. Geographically, there was some overlap:
- 118 of these were done in the US
- 43 studies in the Netherlands
- 60 studies in New Zealand, the UK, Europe, Canada and Australia
- 9 in Brazil, Israel, and Turkey
The team reviewed all clinical studies for risk of bias.
13 studies ranked as high risk of bias. The rest were graded at fair or low risk of bias.
What is bias in clinical studies?
Bias in clinical studies is described as factors which make the study’s conclusions less likely to describe what is actually happening. It is a very important part of completing a literature review.
Experimental Studies
36 studies met their criteria for inclusion (youth, was there an intervention studied, and was there a comparative group that did not receive an intervention?)
Observational Studies
83 observational studies met eligibility criteria.
Descriptive Studies
144 descriptive studies met eligibility criteria.
OUTCOMES in OBSERVATIONAL AND DESCRIPTIVE STUDIES
On Mental Health
- Rates of depression, suicidal thoughts, and self-harm tend to be lower among hormonally treated transgender youth compared to untreated transgender individuals.
- Staring hormones has a neutral to positive effect on mental health.
- Scores for gender dysphoria tend to decline after treatment.
On Psychosocial Functioning
- Youth who receive hormonal therapy have higher quality of life scores and lower problem scores compared to untreated youth.
On Body Image
- Youth who receive hormonal therapy have improvements in body image satisfaction compared to untreated youth.
On Bone Health
- Bone mineral density tends to be lower in trans girls compared to trans boys. Bone mineral density tends to decline, but then evens out over time.
On Cardiovascular risk factors
- Some cardiovascular risk factors increase, particularly in trans boys but they tend to stay within normal range. They also often plateau or return to normal.
On Discontinuation
- What are the short and long-term rates of discontinuation among youth who start a blocker or hormones?
The team identified 32 studies that discussed persistence, desistance, and/or regret.
OUTCOMES ON DISCONTINUATION
Rates of persistence are high. Rates of regret are low. When discontinuation occurs, a significant amount of individuals re-start, or stopped due to reasons other than dissatisfaction (insurance or other money issues, youth stopped because they were satisfied with changes, etc.).
- Of 11 youth who were interested in fertility preservation, 2 paused care for fertility preservation (18%)
- Of 143 youth who started blockers
- 5 were not eligible to start hormones
- 125 started hormones
- 9 discontinued blockers (6%)
- 5 were no longer interested in gender affirming treatment (3.5%)
- 4 were pausing and later restarted (2.3%)
- Of 1089 youth who were referred to British gender identity clinics between 2008 and 2021 and were followed until 2022
- 999 had no change in their gender identity (91.7%)
- 32 reverted to birth gender and never started hormone therapy (2.9%)
- 58 started hormone therapy and then reverted to birth gender (5.3%)
- Of 44 youth on blockers at a gender clinic in Brazil
- 1 chose not to start adding hormones
- Of 21 youth and their parents who were interviewed about the decision-making process
- 0 expressed regret about starting hormone therapy
- Of 68 youth requesting hormonal therapy or surgery in the US
- 4 withdrew their request before starting treatment (5.9%)
- 2 withdrew their request after starting treatment (2.9%)
- 14 withdrew their request and then re-requested treatment (20.6%)
- Of 27 youth at a Dutch clinic who underwent hormone treatment and surgery, 0 expressed regret.
- Of 55 adults at a Dutch clinic who were followed since care while youth, 100% were generally satisfied with their physical appearance and 0% regretted treatment.
- etc. – see report. The discussion of studies on persistence, desistance, and regret starts on page 109.
Who Did The Work on Utah’s Evidence Review?
The Utah Department of Health and Human Sciences
Unlike the HHS report, the people who worked on the Utah are named in the report, and appear to be qualified to do the work. They include six individuals with PharmDs, or individuals who have doctorates in pharmacy. Two of those are working on second doctoral degrees. Two more are currently working on their Pharmacy doctorates. One is a registered clinical pharmacist without a doctorate. The group director also has a Master’s of Public Health.
These people know their stuff and ARE QUALIFIED. They have been trained to do this work.
What They Did
They did a true evidence review. They:
- Searched multiple databases for studies about trans youth, using clear search terms and qualifiers:
- were they a guideline or a clinical study?
- did the study include findings reported separately for youth ?
- They then evaluated each study to determine which ones to look at in depth and which ones to include in the bibliography, but not to include in the data tables using established tools to rank risk of bias, strength of evidence, and reproducibility.
- They shared those evaluations.
- They included a bibliography of ALL of the studies that met eligibility requirements.
- And they described their methods, including the tools they used to evaluate the studies.
- They documented everything. Nothing to hide here.
QueerDoc Background Readings
- Doing It For Science: How To Read A Medical Journal Article, April 2025
- Reading The Evidence – Let’s Get This Party Started (April 2025)
- Community and Organizational Responses to the HHS Youth Gender Affirming Care Report
- Roundup on the Controversial Cass Review, May 2024
- Sharing What Others Have Written About The Evidence Supporting Gender Affirming Care
- Trans Healthcare Is Not A New Phenomenon: TDOV QueerCME TikTok Series
Other Articles on Utah’s Evidence Review
- Mother Jones, Utah Study on Trans Youth Care Extremely Inconvenient for Politicians Who Ordered It
- TransVitae, New Study Validates Gender Affirming Care for Adolescents
- The Salt Lake Tribune, Utah lawmaker’ own study found gender-affirming care benefits trans youth. Will they lift the treatment ban?
- Assigned Media, Plentiful Data, No Regret: What the Utah Review on Youth Trans Care Found
- Associated Press, Utah lawmakers said gender-affirming care is harmful to kids. Their own study contradicts that claim.
related:
- Erin In The Morning, Landmark Report Finds Major Flaws in the Cass Review
- Scientific American, The U.K.’s Cass Review Badly Fails Trans Children
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