On Thursday, the U.S. Department of Health and Human Services released a comprehensive report examining the “insurance coding practices, perverse financial incentives, and the provision of sex-rejecting procedures for minors.” The report, Wolves in White Coats: How Doctors and Hospitals Pushed and Profited from the Fraud of "Gender Medicine," draws on nationwide insurance claims analyses, billing code guidance, hospital records, patient testimony, and medical society guidance to expose the incentives driving youth gender medicine. Furthermore, the report proposes recommendations for reforming related insurance and billing coding practices, and clinical practices and policies. Among the report’s troubling findings is the widespread use of false billing codes—like Endocrine Disorder, Unspecified and Precocious Puberty—to facilitate access to medical transition procedures. The report also includes a short documentary that highlights its main findings.
Earlier this week, HHS announced a final rule which ends the use of federal Medicaid and CHIP funds to pay for medical transition procedures for patients under 19. For patients currently undergoing hormone therapy, CHIP and Medicaid funds will remain available for a six-month taper off period. “CMS’s decision follows a review of national and international research by the U.S. Department of Health and Human Services that identified significant evidence gaps, documented serious safety concerns, and concluded that the evidence supporting these interventions for children remains insufficient to justify federal taxpayer funding,” the press release reads. The rule will take effect on October 13th.
The Society for Evidence-Based Gender Medicine (SEGM) highlights a new court filing by the World Professional Association for Transgender Health (WPATH) in its case with the Federal Trade Commission, where it walks back several of its previous claims. In the filing, WPATH argues that its clinical recommendations represent only one side “of an unsettled scientific debate,” while holding up the UK’s Cass Review as a foil for the alternative position. WPATH argues that its recommendations are “opinions” which are expressions of its “free speech.” Ironically, WPATH draws on Supreme Court rulings in both Skrmetti and Chiles v. Salazar to argue its positions. “If its recommendations are merely one ‘opinion’ in a legitimate debate defined by ‘uncertainty,’ and if doctors should judge independently whether to follow them, why should insurers follow them? Why should judges defer to them as the accepted standard of care? Why should other medical groups endorse or at least not oppose them?” Leor Sapir Shrewdly notes on twitter.
California Attorney General Rob Bonta has filed an amicus brief in support of two trans-identified plaintiffs challenging Idaho’s HB264, which prohibits students from using certain public educational facilities based on their “gender identity.” The brief argues that the district court hearing the case should grant a preliminary injunction in favor of the plaintiffs, and that the law violates the Equal Protection Clause of the constitution. “Idaho’s law is an unconstitutional threat to the safety and privacy of transgender and gender-conforming students,” said Attorney General Bonta. “No one should feel uncomfortable or be afraid to use a public restroom because of their gender identity.”
In City Journal, Leor Sapir reviews a new book about the history of “gender identity” by UCLA sociologist Rogers Brubaker. Brubaker traces the evolution of “gender identity” as a concept and explains how it mutated from shorthand for knowledge of one’s biological sex into the understanding that one’s identity could override sex, reaching its apotheosis in “affirming care.” “This new understanding of gender identity as a patient-controlled, patient-empowering category was codified in the paradigm of ‘gender-affirming care,’” Brubaker writes. “Brubaker has managed to pull off something quite extraordinary, offering a compelling analysis of gender identity’s career. That he manages to do it in such a short book is a testament to his ability to grasp the bigger picture. To be sure, it means that key aspects of the story have been left out, but the tradeoff is worth it,” Sapir concludes.
A new study published by Cambridge University Press challenges the foundations of “minority stress theory,” a theory which presupposes that documented mental health disparities among certain minority groups are the product of stigma and discrimination. Critics of minority stress theory often point out that the associations between poor mental health and reports of discrimination are correlational and confounded by temperamental and personality factors which have a strong genetic basis. The authors performed a multi-level, meta-analysis of seventeen studies where twins reported both sexual orientation and mental health status to evaluate the role played by genes in shaping both sexual orientation and mental health. “The mental health disparity between non-heterosexual and heterosexual persons is reduced by up to two-thirds once familial background factors are accounted for by comparing monozygotic twins discordant for sexual orientation. This suggests that shared familial causes, and not minority stress, are the most important causes of mental health disparities in non-heterosexual persons,” the authors conclude.
As part of Singapore’s new guidelines for gender dysphoria, minor patients receiving medical treatment for gender dysphoria will be allowed to maintain treatment until they have been assessed by a multidisciplinary review panel. Singapore’s new guidelines prioritize psychological support as the required first step before other interventions. Moreover, puberty blockers are not allowed under the new guidelines. The assumption is that after being assessed by a review panel, some patients will be allowed to continue treatment, while others will not. “The diagnosis,” Health Minister Ong Ye Kung said, “needs to be robust, and treatment decisions must be based on the best available clinical evidence and the patient's best interests.”
A new survey of the Dutch population suggests that much of the adult population supports psychological, rather than medical interventions, as the 1st line treatment for pediatric gender dysphoria. Out of 4,179 voters, 75% believed that psychological interventions should be the main priority, with only 5% of the sample answering, “puberty blockers.” Similarly, a question about what values should guide treatment considerations in an area of uncertainty reveals that nearly two thirds of the sample supported more cautious approaches. As I recently covered in City Journal, the Netherlands’ Health Council reviewed and re-endorsed the controversial Dutch protocol for youth gender dysphoria at the end of June.
Joseph Figliolia
Policy Analyst
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