DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop C2-21-16
Baltimore, Maryland   21244-1850

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Center for Clinical Standards and Quality/QUALITY & S

AFETY SPECIAL ALERT MEMO

DATE:

March 5, 2025

Ref: QSSAM-25-02-Hospitals

  TO:

Hospital Providers and other Covered Entities

  FROM:

Centers for Medicare & Medicaid Services (CMS)

SUBJECT:  Protecting Children from Chemical and Surgical Mutilation

Memorandum Summary

•  CMS is alerting providers to the dangerous chemical and surgical mutilation of children,
including interventions that cause sterilization. CMS is reminding providers of the
program requirements of hospitals to serve all patients, especially children, with dignity
and adherence to the highest standard of care that is informed by robust evidence and the
utmost scientific integrity.

Discussion:

•  Other developed nations have taken decisive actions to prohibit or significantly limit these

mutilation practices to ensure that children are protected from harmful, unscientific
medical interventions.

•  This alert is notice that CMS may begin taking steps in the future to align policy,

including CMS-regulated provider requirements and agreements, with the highest-quality
medical evidence in the treatment of the nation’s children in order to protect children
from harmful, often irreversible mutilation, including sterilization practices. CMS will
follow any applicable substantive and procedural requirements in taking any future action.

Discussion:
CMS renews its commitment to promoting evidence-based standards through health quality and
safety improvement activities, and reminds hospitals and other applicable facilities and providers
of the obligation to prioritize the health and safety of their patients, especially children.  In recent
years, medical interventions for gender dysphoria in children have proliferated. Initiated with an
underdeveloped body of evidence and now known to cause long-term and irreparable harm to
some children, CMS may begin taking steps in the future to adjust its policies to reflect this
reality and the lack of medical evidence in support of these harmful treatments.
Around 85% of children with reported gender dysphoria—which includes more than 300,000
children between the ages of 13 and 17—do not suffer this condition throughout their

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adolescence.1 2 There is no reliable method by which the minority whose gender dysphoria will
persist can be identified with confidence during childhood.3 However, thousands of children
have received chemical or surgical interventions that, in many cases, are irreversible.

One study estimated in 2023 that nearly 3,700 children with gender dysphoria between the ages
of 12 to 18 from 2016 to 2020 underwent surgical procedures, including over 3,200 children who
had breast or chest surgery and over 400 children who had genital surgery resulting in permanent
alterations to reproductive organs and impaired sexual function.4  Another study found that
between 2017 to 2021, more than 120,000 children ages 6 to 17 were diagnosed with gender
dysphoria and, of that group, more than 17,000 started taking puberty blockers or cross-sex
hormones.5 And a database composed of claims data estimated that nearly 14,000 minors
underwent such treatments between 2019 and 2023.6

Organizations such as the Mayo Clinic have shown the potentially harmful long-term effects of
puberty blockers related to children’s growth spurts, bone growth, bone density, and fertility.7 A
panel of experts in neurodevelopment, puberty and adolescence, statistics, and other fields have
acknowledged that “the existing knowledge about puberty and the brain raises the possibility that
suppressing sex hormone production during this period could alter neurodevelopment in complex
ways – not all of which may be beneficial.”8

In several notable instances, research used to promote these harmful procedures on children
contained obvious and significant methodological flaws or demonstrated outright scientific
misconduct.9 CMS notes ongoing debate about: the long-term outcomes for children undergoing
these procedures; whether puberty blockers may impact bone density, fertility, and brain
development; and the experience of children who later “detransition.”10

The U.S. is now an outlier in the treatment of gender dysphoria in children. The United
Kingdom, Sweden, and Finland have recently issued restrictions on the medical interventions for
children, including the use of puberty blockers and hormone treatments, and now recommend

1 Steensma, T.D. et al., “Gender identity development in adolescence,” Hormones and Behavior, July 2013, 64(2) pp
288-297, https://www.sciencedirect.com/science/article/abs/pii/S0018506X13000676.
2 Herman, J.L., Flores, A.R., O’Neill, K.K., “How Many Adults and Youth Identify As Transgender in the United
States?” June 2022, https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/.
3 American College of Pediatricians, “Gender Dysphoria in Children,” November 2018, https://acpeds.org/position-
statements/gender-dysphoria-in-children.
4 Wright, J.D., Chen, L., Suzuki, Y., et al., “National Estimates of Gender-Affirming Surgery in the US,” Jama Netw
Open. August 23, 2023, 6(8), https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2808707.
5 Respaut R. & Terhune, C., “Putting numbers on the rise in children seeking gender care,” Reuters, October 6,
2022, https://www.reuters.com/investigates/special-report/usa-transyouth-data/.
6 Do No Harm, “Stop the Harm Database,” https://stoptheharmdatabase.com/about/. Accessed March 4, 2025.
7 Mayo Clinic, “Puberty blockers for transgender and gender-diverse youth,” June 14, 2023,
https://www.mayoclinic.org/diseases-conditions/gender-dysphoria/in-depth/pubertal-blockers/art-20459075.
8 Chen, D. et al., “Consensus Parameter: Research Methodologies to Evaluate Neurodevelopmental Effects of
Pubertal Suppression in Transgender Youth,” Transgender Health, December 11, 2020, 5(4),
https://www.liebertpub.com/doi/10.1089/trgh.2020.0006.
9 Do No Harm, “Major Pediatric Gender Studies, Major Flaws,” September 23, 2024,
https://donoharmmedicine.org/research/2024/major-pediatric-gender-studies-major-flaws.
10 Jorgenson S.C.J., et al., “Puberty blockers for gender dysphoric youth: A lack of sound science,” Journal of the
American College of Clinical Pharmacy, September 15, 2022 5(9),
https://accpjournals.onlinelibrary.wiley.com/doi/10.1002/jac5.1691.

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exploratory psychotherapy as a first line of treatment and reserve hormonal interventions only
for exceptional cases.11 12 13

In particular, the “Cass Review,” an independent review of the evidence in the United Kingdom,
noted that despite the considerable research in the field of gender dysphoria in children,
“systematic evidence reviews demonstrated the poor quality of the published studies, meaning
there is not a reliable evidence base upon which to make clinical decisions, or for children and
their families to make informed choices.”14

CMS reminds hospitals that it is of utmost importance that all providers follow the highest
standards of care and adhere closely to the foundational principles of medicine, especially as it
comes to America’s children. This CMS alert to providers on the dangerous chemical and
surgical mutilation of children, including interventions that cause sterilization, is informed by a
growing body of evidence and protective policies across the world. CMS may begin taking steps
to appropriately update its policies to protect children from chemical and surgical mutilation.
CMS will follow any applicable substantive and procedural requirements in taking any future
action.

Effective Date:
Immediately.  Please communicate to all appropriate staff within 30 days.

11 NHS England, “Children and young people’s gender services: implementing the Cass Review recommendations,”
August 29, 2024, https://www.england.nhs.uk/long-read/children-and-young-peoples-gender-services-implementing-
the-cass-review-recommendations/.
12 Socialstyrelsen, “Care of children and adolescents with gender dysphoria,” December 2022,
https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/kunskapsstod/2023-1-8330.pdf.
13 Society for Evidence Based Gender Medicine, “One Year Since Finland Broke with WPATH ‘Standards of Care,’”
July 2, 2021, https://segm.org/Finland_deviates_from_WPATH_prioritizing_psychotherapy_no_surgery_for_minors.
14 Cass, H., “Independent review of gender identity services for children and young people: Final report,” April
2024, https://cass.independent-review.uk/home/publications/final-report/.

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