On May 19, Alliance Defending Freedom and the state of Alabama filed an expert report written by Dr. James Cantor in Boe v. Marshall.
In this case, the Biden administration and politicized interest groups are challenging a commonsense Alabama law (SB 184) which, among other things, prohibits the administration of puberty blockers, cross-sex hormones, and surgeries on minors who experience discomfort with their biological sex. ADF is assisting the state of Alabama to protect children from these dangerous, unproven, unnecessary, and potentially sterilizing medical procedures for minors.
Dr. Cantor’s expert report details the scientific evidence surrounding treatments of gender dysphoria and the effects of “medically transitioning” children, especially as it pertains to the use of puberty blockers and cross-sex hormones.
Who is Dr. James Cantor?
Dr. James Cantor is a sexual behavior scientist. He has an internationally acclaimed record in studying the development of human sexuality and in research methodology of sexuality.
Over the course of his career, Dr. Cantor has published over 50 peer-reviewed articles in his field. As a clinical psychologist and neuroscientist, he has held positions at the Centre for Addiction and Mental Health (CAMH) as senior scientist and psychologist as well as head of research for CAMH’s Sexual Behavior Clinic. For 15 years, he was editor-in-chief of the peer-reviewed journal Sexual Abuse. He has also served on the editorial boards of The Journal of Sex Research, the Archives of Sexual Behavior, and the Journal of Sexual Aggression. In 2022, he was awarded the Distinguished Contribution Award from the Association for the Treatment and Prevention of Sexual Abuse.
Below is a summary of Dr. Cantor’s expert report. You can read the full report below. It is detailed, and backed by extensive citations to the scientific literature.
Summary of Dr. Cantor’s report
1. International health care systems are reversing course on medically transitioning minors
U.S. government officials and non-governmental organizations often assert that there is a wide consensus and “no debate” when it comes to the research and medical transitions of minors.
But research from multiple health-care institutions in England, Finland, Sweden, France, and Norway point out the “experimental” nature of these procedures, and that the data (especially the long-term effects) is “inconclusive” and “insufficient.” Many of the medical interventions are noted to be potentially “irreversible,” and can result in serious complications like risks of impaired brain development or lifelong sterility, and have not demonstrated gains in psychological well-being for minors who undergo them.
Some of the institutions who have conducted this research include the English National Health Service (NHS), the Swedish National Board of Health and Welfare, the Council for Choices in Health Care in Finland, and Norway’s Health Investigation Board.
Dr. Cantor remarks that instead of providing “medicalized transition of minors,” these European health-care institutions “now endorse psychotherapy as the treatment of choice for minors, with medical interventions representing a method of last resort, if permitted at all.”
2. Using puberty blockers and cross-sex hormones to ‘transition’ is neither ‘safe’ nor ‘reversible’
Advocates of using puberty blockers and cross-sex hormones on minors claim that such methods are “safe.” As Dr. Cantor notes, however, “This claim is unsupported by any substantial scientific evidence, depreciates widely recognized risks of serious harm to minors so medicalized, and ignores both the many unknowns and the growing international doubts about their use.”
The few studies that have been done on the effects of using puberty blockers and cross-sex hormones on minors are of poor methodological quality. Systematic studies done by national health-care institutions in England, Finland, and Sweden all concluded “that there is insufficient evidence to determine that hormonal interventions as treatments for gender dysphoria in minors are safe.”
Professional associations based in the U.S., including the Endocrine Society, the World Professional Association for Transgender Health (WPATH), and the American Academy of Pediatrics have not conducted systematic reviews that included both safety and efficacy. Without both, they are unable to properly assess the risk-to-benefit ratio. Yet that hasn’t stopped them from developing guidelines for medically transitioning minors, relying on “consensus-based expert opinion” rather than “evidence-based medicine.”
It is also incorrect to call such treatments reversible. As Dr. Cantor notes with puberty blockers, “Although withdrawal of the medication will allow the pubertal process to resume, that is very far from establishing that the impact of that interruption of natural development is ‘fully reversible.’ The evidence is not that the person’s life will proceed as if the medical intervention never happened, as the popularized phrase suggests. Rather, the evidence repeatedly indicates that stopping a healthy child’s natural onset of puberty imposes multiple substantial harms, risks, or opportunity costs.”
3. Puberty blockers and cross-sex hormones already carry known and potential risks
According to Dr. Cantor, once children begin socially transitioning, they are much more likely to medically transition, and those who start taking puberty blockers will likely go on to cross-sex hormones. Medicalized transition carries with it numerous risks, with few rigorous studies having been done on these effects:
- Sterilization: Once puberty blockers are followed by cross-sex hormones, “no viable fertility preservation options exist. The decision to undergo medicalized transition also represents the decision never to have biological children of one’s own.”
- Loss of capacity to breastfeed: If breasts are removed during medicalized transition, that functionality cannot be restored.
- Loss of sexual functionality and pleasure: Unsurprisingly, blocking pubertal development can hinder proper sexual development and experience later in adulthood.
- Interference with neurodevelopment and cognitive development: Crucial brain developments during puberty are driven by natural hormone changes. Thus, using puberty blockers can delay or impair that crucial brain development.
- Delayed puberty associated with medical harms: Children in whom puberty naturally starts very late have associated risks with “metabolic and cardiovascular disease, lower height, and decreased bone mineral density… poorer psychosocial functioning and lesser educational achievement.” It is unknown whether chemically delaying puberty will have the same effects.
- Elevated risk of Parkinson’s disease: Epidemiological research has shown that women who have their ovaries removed have “substantially elevated odds of developing parkinsonism, including Parkinson’s Disease,” with the effect being 7-8 times greater among women under age 43. It is unknown whether chemically suppressing the ovaries could have the same effect.
- Reduced bone density: One of the better-studied effects of medical transition is the effect on bone density. In a review done by The New York Times, while on blockers, teens did not gain bone density and “lost significant ground compared to their peers.” Some of this loss was reversible on females, but not males.
- Other side effects: Other short-term side-effects of using puberty blockers may include sterile abscesses, leg pain, headaches, mood swings, weight gain, tiredness, hot flushes, low mood and anxiety, etc.
- Lifetime medical care: Dr. Cantor says that “[m]inors who begin puberty blockers and proceed to cross-sex hormones—as almost all do—will require continuing treatment with cross-sex hormones for life.” Using hormones into adulthood can result in increased cardiovascular risk, osteoporosis, and hormone-dependent cancers.
4. Far from being ‘medically necessary,’ medically transitioning minors has no reliably proven mental health benefits
Dr. Cantor plainly states, “No studies have documented any reduction in suicide rates in minors (or any population) as a result of medical transition. No methodologically sound studies have provided meaningful evidence that medical transition reduces suicidality in minors. Instead, multiple studies show tragically high rates of suicide after medical transition, with that rate beginning to spike several years after medical transition.”
Studies from Sweden, the Netherlands, and the United Kingdom showed that rates of suicide still remained extremely elevated (five to 19 times higher) or were not reduced post-transition. Even WPATH, when judging the effectiveness of puberty blockers and cross-sex hormones, admitted that “it was impossible to draw conclusions about the effects of [either] hormone therapy on death by suicide.”
The evidence also does not support suicidality (suicidal ideation, threats, and gestures) being reduced by transition. One study even found that minors receiving hormone treatment showed “increases in each of suicidal ideation (from 25% to 38%), attempts (from 2% to 5%), and non-suicidal self-injury (10% to 17%).”
In addition, some research has found “social support to be associated with increased suicide attempts, suggesting the reported suicidality may represent attempts to evoke more support.”
With regard to other mental health measures, 11 cohort studies on the use of puberty blockers and cross-sex hormones in minors “provide no reliable evidence of effectiveness for improving mental health” relative to normal mental health treatments that lack medical risk, such as regular psychotherapy. In other words, it is unwarranted to try these risky, experimental, and potentially dangerous medical transitions when other treatments like normal psychotherapy might improve mental health on their own.
Given this lack of evidence, the major international institutions studying gender dysphoria in England, Finland, Sweden, Norway, and the Netherlands all regard medical transitions as experimental. One official from England even went so far as to write that “these treatments cannot formally be called ‘experimental’ not because they are proven, but because the experiments needed to test their efficacy and safety have not only not been done, but are not even being attempted.”
Despite international bodies rightly recognizing the experimental nature of these procedures, U.S. institutions assert that they are “medically necessary” for individuals with gender dysphoria. But such assertions are without merit and are being made because health insurance will only cover “medically necessary” procedures, not “experimental” ones.
5. Minors diagnosed with gender dysphoria also tend to struggle with other mental-health issues
According to multiple studies cited by Dr. Cantor, for children 11 years old and under diagnosed with gender dysphoria, more than half also met the criteria for “one or more mental health conditions other than gender dysphoria.”
A common co-occurring mental health condition with gender dysphoria is autism spectrum disorders (ASD). One systematic review of 22 studies found that children and adolescents referred to clinics for gender dysphoria are also diagnosed with ASD at a rate of six to 26 percent. Conversely, another study found that children diagnosed with ASD are “seven times more likely to have parent-reported ‘gender variance.’”
Among adolescents with gender dysphoria, “clinical assessments reveal elevated rates not only of depression … but also anxiety disorders, disruptive behavior difficulties, Attention Deficit/Hyperactivity Disorder, Autism Spectrum Disorder, and personality disorders, especially Borderline Personality Disorder (BPD).”
Because of overlapping symptoms between some diagnoses (e.g., BPD) and gender dysphoria, many children and adolescents may be incorrectly diagnosed with gender dysphoria when that is not the real issue. Mistaken cases like this “may prevent such youth from receiving the correct mental health services for their condition.”
Recently, numerous international bodies have documented the staggering increase in diagnoses for gender dysphoria among teens and adolescents during the last 10-15 years:
- England’s NHS reported a 40-fold increase in referrals to the country’s Gender Identity Development Service between 2008 and 2018.
- Sweden’s Board of Health and Welfare reported that, between 2008 and 2018, the number of diagnoses of gender dysphoria was 15 times higher among girls ages 13-17.
- Norway’s Healthcare Investigation Board noted that referrals to its national treatment service increased by a factor of eight (2007-2018), mostly from girls.
These statistics demonstrate the need to consider sociological (and perhaps financial) factors contributing to increased diagnoses. Based on the current evidence, France’s Académie Nationale de Médecine attributed this drastic rise in youth requesting medical transition to social media.
6. Most young children with gender dysphoria will become comfortable with their biological sex (desist) after puberty
Prepubescent children have shown markedly different results if they have been allowed to socially transition (using different names or pronouns of the opposite sex, cross-dressing, etc.). Eleven cohort studies done on children not permitted to socially transition showed they became comfortable with their biological sex between 61 and 88 percent of the time. In sharp contrast, one cohort study on children who were permitted to socially transition showed that 92.7 percent of children persisted in feeling gender-dysphoric.
As Dr. Cantor has demonstrated, the science of gender dysphoria and the effects of medicalized “treatments” is far from settled. Unlike what its proponents claim, there is no consensus that makes socially or medically transitioning a minor a medical necessity or even the preferred method of treatment.
In fact, quite the opposite.
From what evidence we do have, medical transition is experimental, carries known and potentially severe risks, and has not been demonstrated to provide any tangible benefits to those who undergo such procedures.
Alabama is right to prohibit these procedures being performed on minors.