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Dr. Stephen B. Levine is an expert in gender dysphoria and gender identity. He is a Distinguished Life Fellow of the American Psychiatric Association and a professor with many years of experience in the fields of gender and sexuality.
Dr. Levine chaired a committee that crafted a pioneering set of standards of care for individuals suffering from gender dysphoria, and he has been a senior editor for three editions of the Handbook of Clinical Sexuality for Mental Health Professionals. He also founded a gender identity clinic in 1974, which he continues to lead as co-director.
To put it simply, Dr. Levine is a highly respected expert in his field. And he has served as an expert witness in multiple Alliance Defending Freedom cases.
As an expert witness, Dr. Levine speaks about the dangers of treatments dictated by gender ideology rather than science. We summarize his key arguments here, but you can read a recent version of his full export report in an ADF case below.
Dr. Levine’s research concludes that social transition of children is an experimental therapy that exposes vulnerable children to dangerous lifelong physical, social, and mental health risks. Here are six of his conclusions.
1. There is no expert consensus regarding therapeutic approaches to child or adolescent gender dysphoria
Experts differ as to how gender dysphoria ought to be treated in children and young adults.
“There is far too little firm clinical evidence in this field to permit any evidence-based standard of care,” Dr. Levine writes in his expert report. “Given the lack of scientific evidence, it is neither surprising nor improper that … there is a diversity of views among practitioners as to the best therapeutic response for the child, adolescent, or young adult who suffers from gender dysphoria.”
A pair of Dutch studies conducted in the 2010s—the so-called “Dutch protocol”—have proven influential in shaping therapeutic approaches to gender dysphoria around the world. In particular, Dr. Levine writes that the Dutch protocol has often been used to justify the use of puberty blockers.
Both the Endocrine Society and the World Professional Association for Transgender Health (WPATH) have cited the Dutch protocol as a basis for their recommendations of puberty blockers and cross-sex hormones. But internationally, the initial enthusiasm regarding this approach has cooled.
Sweden and Finland have each reversed course on the question of administering puberty blockers to minors. In the latter country, public health authorities concluded that “[i]n light of available evidence, gender reassignment of minors is an experimental practice” (COHERE 2022).
Dr. Riittakerttu Kaltiala, chief psychiatrist in the department of adolescent psychiatry at Finland’s Tampere University Hospital, led her country’s pediatric gender program. In an essay for The Free Press, Dr. Kaltiala decried the application of the Dutch protocol, noting “serious problems” with the data and describing the protocol’s foundation as “crumbling.”
“When medical professionals start saying they have one answer that applies everywhere, or that they have a cure for all of life’s pains, that should be a warning to us all that something has gone very wrong,” Dr. Kaltiala wrote.
In the United Kingdom, a much-anticipated review by Dr. Hillary Cass outlined the lack of evidence supporting social and medical “transition.” In a series of systematic reviews accompanying the report, a team of researchers wrote of puberty blockers that “[n]o conclusions can be drawn about the effect on gender-related outcomes, psychological and psychosocial health, cognitive development or fertility” (Taylor et al. 2024). The team reached similar conclusions regarding the administration of cross-sex hormones.
Following the publication of the Cass report, England’s National Health Service stopped prescribing puberty blockers, and the U.K. government imposed an “emergency ban” on such prescriptions in England, Wales, and Scotland. The ban was later extended.
2. Transgender identity is not biologically based
“There is no medical consensus that transgender identity has any biological basis,” Dr. Levine writes in his report. “Gender dysphoria is defined and diagnosed only as a psychiatric, not a medical, condition.”
He goes on to explain that the concept of a biological basis for transgender identity is merely a hypothesis, not fact. And there is much evidence that such a hypothesis is incorrect.
Reported rates of gender dysphoria and transgender identification have risen dramatically in recent years. While a 2013 estimate placed the incidence of gender dysphoria in adults at .002-.014 percent, more recent surveys (2019 and 2021) indicate that “between 2-9% of high school students self-identify as transgender or ‘gender non-conforming.’”
“The rapid change in the number of individuals experiencing gender dysphoria,” Dr. Levine writes, “points to social and cultural, not biological, causes.”
Dr. Levine also highlights a handful of other factors that weigh against the hypothesis of a biological basis for transgender identity. One is the significant change in sex ratio among patients presenting with gender dysphoria or transgender identification. He quotes clinical psychologist Dr. Erica Anderson:
“The data are very clear that adolescent girls are coming to gender clinics in greater proportion than adolescent boys. And this is a change in the last couple of years. And it’s an open question: What do we make of that? We don’t really know what’s going on. And we should be concerned about it.”
As an example of this phenomenon, Dr. Levine cites London’s Tavistock clinic, which saw its ratio of female to male patients shift from 4:5 to 11:4.
Dr. Levine further points to the documentation of “clustering,” in which instances of gender dysphoria have been observed in particular schools and among friend groups. He also brings up the concept of desistance:
“[T]here are very high levels of desistance among children diagnosed with gender dysphoria, as well as increasing (or at least increasingly vocal) numbers of individuals who first asserted a transgender identity during or after adolescence, underwent substantial medical interventions to ‘affirm’ that trans-identity, and then ‘desisted’ and reverted to a gender identity congruent with their sex.”
Finally, therapeutic choices themselves can affect gender identity outcomes. Dr. Levine specifically mentions the “social transition” of adolescents.
3. The large majority of children diagnosed with gender dysphoria ‘desist’
Dr. Levine writes, “The large majority of children who are diagnosed with gender dysphoria ‘desist’—that is, their gender dysphoria does not persist—by puberty or adulthood.”
Across multiple studies, separate groups, and different times, most patients desist “absent a substantial intervention such as a social transition or puberty blocking hormone therapy.”
In 2021, physician and researcher Lisa Littman conducted a study of 100 teenage and young adults who had “transitioned” and then “de-transitioned” to a gender identity matching their sex. Dr. Levine writes that among study participants, 60 percent said their decision to de-transition “was motivated (at least in part) by the fact that they had become more comfortable identifying as their natal sex.” Additionally, 38 percent of participants identified trauma, abuse, and mental health conditions as causing their gender dysphoria.
4. Transition and ‘affirmation’ are experimental approaches that can radically alter children’s lives
Contrary to being part of a treatment for gender dysphoria, “social transition has a critical effect on [its] persistence,” Dr. Levine writes in his report.
“It is evident from the scientific literature that engaging in therapy that encourages social transition before or during puberty—which would include participation on athletic teams, being addressed as a member of a new gender with a new name and pronouns, and using different bathrooms (designated for the opposite sex)—is a psychosocial intervention that dramatically changes outcomes.”
How so? Dr. Levine writes that “studies conducted before the widespread use of social transition for young children reported desistance rates in the range of 80-98%, [while] a more recent study reported that fewer than 20% of boys who engaged in a partial or complete social transition before puberty had desisted when surveyed at age 15 or older.”
What’s more, some practitioners of social transitioning are proud of the extremely low rates of desistance among the children who exhibit gender dysphoria and visit their clinics.
“The fact is that these unproven interventions with the lives of kids and their families have systematically documented outcomes,” Dr. Levine writes.
In addition to social transitioning, the administration of puberty blockers is “a powerful medical and psychosocial intervention that radically changes outcomes.”
Dr. Levine goes on to review studies regarding puberty blockers, citing one which found that “98% of adolescents who underwent puberty suppression continued on to cross-sex hormones.”
“Rather than a ‘pause,’ originally a rhetorical device to minimize its dangers, puberty blockers appear to act as a psychosocial ‘switch,’ decisively shifting many children to a persistent transgender identity.”
5. Parental involvement is essential for children who may be suffering from gender dysphoria
When it comes to children who may be suffering from gender dysphoria or claiming a transgender identity, the significance of parental involvement must not be dismissed.
“What can be observed by a schoolteacher or counselor, although important, is only one limited window into the multi-faceted life and psyche of a child,” Dr. Levine writes.
By contrast, parents “typically have observed the child over his or her entire lifetime, and so will have unique insight into whether the child’s attraction to a transgender identity is longstanding and stable, or whether it has been abrupt and associated with intensive online interaction with transgender ‘communities.’”
Dr. Levine states his conclusion in no uncertain terms: “For a child to perform different gender identities and gender roles at home and at school, including situations where parents are kept in ignorance about his or her current self-concepts, is inherently psychologically unhealthy. No professional medical organization has endorsed such an approach.”
6. There are many risks associated with ‘affirming’ transgender identities in children
As mentioned above, Dr. Levine calls out the falsehood that puberty blockers are simply a benign “pause” of puberty. But he also explains the lack of knowledge regarding long-term outcomes.
While puberty blockers are typically administered beginning in a child’s early adolescence and continuing for years, “medicine does not know what the long-term health effects on bone, brain, and other organs are of a ‘pause’ between ages 11-16.” Dr. Levine mentions possible “long term” effects in several categories:
- Fertility: Dr. Levine notes that no published study has examined the question of “whether patients ever develop normal levels of fertility if puberty blockers are terminated after a prolonged delay of puberty.”
- Bone strength: Multiple studies have found that puberty blockers have adverse effects on bone density.
- Brain development: The effect of puberty blockers on brain development has not been thoroughly studied.
When it comes to cross-sex hormones, Dr. Levine writes that “all evidence concerning the safety of [their] extended use … is of ‘very low quality.’” One review, considering all scientific studies of cross-sex hormone administration, concluded, “We found insufficient evidence to determine the efficacy or safety of hormonal treatment approaches for transgender women in transition” (Haupt et al. 2020)
Even the Endocrine Society, which recommends cross-sex hormones, has admitted that it bases this recommendation on “low quality evidence.” Guidelines from the organization state that “[p]rolonged exposure of the testes to estrogen has been associated with testicular damage,” that “[r]estoration of spermatogenesis after prolonged estrogen treatment has not been studied,” and that “[i]n biological females, the effect of prolonged treatment with exogenous testosterone upon ovarian function is uncertain.”
And the risks aren’t just physical. Dr. Levine also writes that “[g]ender transition routinely leads to isolation from at least a significant portion of one’s family in adulthood.”
Romantic relationships may also be affected: “After adolescence, transgender individuals find the pool of individuals willing to develop a romantic and intimate relationship with them to be greatly diminished.”
Ushering gender-dysphoric children toward social transition to the opposite sex is an experimental therapy that exposes these vulnerable children to more mental health risks, and Dr. Levine’s expert report only makes that reality clearer.
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