A top Biden Administration health official repeatedly urged an influential transgender advocacy group to remove proposed age minimums for transgender surgical procedures from its policy guidelines, according to recently publicized court documents reported by National Review. Assistant Secretary of Health Rachel Levine, who began identifying as a woman in 2011, believed that the publication of recommended age minimums for transgender procedures would “result in devastating legislation for trans care,” according to emails sent by members of the World Professional Association for Transgender Health (WPATH).

Levine asked the association if references to “specific ages” could be “taken out” of its proposed guidelines, expressing concern that having age minimums, particularly for surgeries, would “affect access to health care for trans youth and maybe adults too.” WPATH, which describes its mission as the promotion of “evidence-based care, education, research, advocacy, public policy, and respect in transgender health,” had previously released draft guidelines recommending a variety of age minimums for transgender procedures. These included age limits of 14 for hormonal treatments such as puberty blockers, 15 for mastectomies, 16 for facial alteration surgeries and breast augmentations, and 17 for genital surgeries and hysterectomies. Levine sought to have WPATH remove the age minimums in the since-released final version of its guidelines.

WPATH staff noted that both Levine and the White House had expressed concern that state-level efforts to restrict transgender procedures for minors could be aided by the guidelines’ endorsement of age minimums. They wrote that “[a]pparently the situation in the USA is terrible and she [Levine] and the Biden administration worried that having ages in the document will make matters worse.”

After Levine’s intervention and an “ultimatum” from the American Academy of Pediatrics threatening to “withhold [its] endorsement” and “publicly oppose” the guidelines if they included recommended age limits, WPATH bypassed its usual consensus-based processes for changing medical guidelines and removed the age minimums from the guidelines’ final version.

The documents also include communications from WPATH members expressing their dissatisfaction with the association’s decision to bend to pressure from Levine and consider potential political implications in crafting its recommendations. “If our concern is with legislation (which I don’t think it should be — we should be basing this on science and expert consensus if we’re being ethical) wouldn’t including the ages be helpful?” one member wrote. “I need someone to explain to me how taking out the ages will help in the fight against the conservative anti trans agenda.”

Emails revealing Levine’s involvement were included among court documents as part of a lawsuit filed in federal court by progressive advocacy groups challenging Alabama’s ban on transgender procedures for minors. The materials were part of a court exhibit submitted by James Cantor, a prominent clinical psychologist and longtime critic of transgender procedures for minors. Cantor wrote that the emails proved that Levine and the Biden Administration “attempted to and did influence the substantive content” of WPATH’s guidelines “based on political goals rather than science.”

The number of transgender-identifying youth seeking chemical and surgical transgender treatments has dramatically increased in recent years. In response, several Western countries, such as Finland, Sweden, and the United Kingdom, have moved to limit access to transgender procedures for minors. Sweden, for example, restricted hormone treatments to “exceptional cases,” while Britain’s publicly-funded National Health Service no longer offers puberty-blocking drugs.

However, consensus has been harder to find in the United States, where state-level efforts to limit access to transgender procedures for minors have been met with intense pushback by progressive organizations and LGBT advocacy groups.

The debate over transgender procedures for minors continues to be a contentious issue in the U.S., reflecting broader societal and political divides over the rights and protections for transgender individuals, particularly youth.