President Joe Biden’s administration pressured at least one health care association to eliminate proposed guidelines that would have discouraged doctors from providing sex-change drugs and surgeries to young children, according to newly released court documents.

Draft guidelines by the World Professional Association for Transgender Health (WPATH) in 2021 set recommended age minimums for certain sex-change procedures. It suggested the age of 14 for hormone therapy, 15 to remove healthy female breasts, 16 to put prosthetic breasts on boys, and 17 to perform genital surgeries on boys and girls.

However, following external pressure from Adm. Rachel Levine — Biden’s assistant secretary for health — WPATH eliminated its age-based recommendations entirely and declined to suggest age minimums for any sex-change drugs or surgeries. Levine, who assumed office in March 2021, is the first person who identifies as transgender to hold a Senate-confirmed position in a presidential administration.

The Biden administration’s influence over WPATH’s guidelines came to light in filings in a court case about an Alabama law that prohibits doctors from providing sex-change drugs to minors and performing sex-change operations on them. The documents show internal WPATH emails that discuss the guidelines and Levine’s suggestions that the association remove its minimum age recommendations.

One email included in the filings says that Levine’s chief of staff said the “biggest concern is the section … that lists specific minimum ages for treatment.” It adds: “She is confident, based on the rhetoric she is hearing in [Washington, D.C.] and from what we have already seen, that these specific listings of ages, under 18, will result in devastating legislation for trans care.”

An email states that Levine’s chief of staff asked whether “the specific ages can be taken out” and whether age-based recommendations can be “published or distributed in a way that is less visible.”

One email states that the “minimal ages for the various gender-affirming medical and surgical intervention are consensus-based” before WPATH ultimately removed it. Another document unveiled in the court filing was a 12-point strategic plan to promote the new guidelines, which admit there is a lack of evidence for their suggestions: “Now that we have reviewed the evidence, we are painfully aware of the gaps in the literature and the kinds of research that are needed to support our recommendations.”

Other emails show that WPATH’s Guideline Development Group suggested altering the language of the guidelines based on concerns that phrases like “insufficient evidence” and “limited data” could be used by Republican lawmakers to justify laws that prohibit doctors from providing sex-change drugs and surgeries for minors.

The filings also claim that the American Academy of Pediatrics (AAP) — the country’s largest association of pediatricians — threatened to oppose WPATH’s guidelines if they maintained the minimum age recommendations.

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WPATH did not respond to a request for comment from CNA. 

Mary Rice Hasson, the director of the Person and Identity Project at the Ethics and Public Policy Center, called Levine’s political pressure “an appalling display of cruel political calculation” and told CNA the WPATH documents show that the association is made up of “radical activists more concerned about pleasing powerful politicians than preventing permanent damage in children.”

“How many children have had their fertility stolen and their bodies mutilated just so the Biden administration could claim a political win?” Hasson said.

Edward Furton of the National Catholic Bioethics Center told CNA the documents are “pretty shocking.” He said Levine is “not offering any kind of scientific or medical advice” but instead is “trying to promote transgenderism among the youth.” 

“These are political opinions, which are coloring their judgments about medical and scientific matters,” Furton stated.

Dr. Michael Artigues, the president of the American College of Pediatricians, which has long opposed sex-change surgeries on children, accused Levine, AAP, and WPATH of prioritizing politics over evidence.

“We are appalled that the AAP and top U.S. health officials put political interests ahead of science and evidence-based health care when it comes to children suffering from gender dysphoria, and that WPATH colluded with both,” Artigues said. “Their actions show that these organizations and the Biden administration are not truly interested in the health and well-being of children and will stop at nothing to push their political agenda.”

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More than half of the states in the country still allow doctors to perform sex-change operations on and provide sex-change drugs to children. However, a growing number of states, most of which are led by Republicans, have begun restricting or banning these medical interventions for minors.