Overview

The Endocrine Society is the largest professional body for hormone specialists. Its clinical practice guideline Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons (2009, revised 2017) is, together with the Standards of Care of the World Professional Association for Transgender Health (WPATH), one of the two documents that most other gender-medicine guidance in the world was built on. It is the main endocrine source behind the puberty-blocker-then-hormones pathway for adolescents.

This page looks at four questions. How closely is the guideline tied to WPATH? How strong is the evidence behind it, by its own ratings and by independent ones? What incentives, ideological and financial, are documented? And how has the Society defended it? Every claim below is sourced to the guideline, court records, government reviews or named reporting. Where something could not be verified, the page says so.

The guideline at a glance

The first version (Hembree et al. 2009) was written by eight authors. Three of them, Peggy Cohen-Kettenis, Henriette Delemarre-van de Waal and Louis Gooren, were from the Amsterdam team that devised the "Dutch protocol" of puberty suppression. The 2009 abstract states that the quality of evidence "was low or very low". It lists the Endocrine Society, the European Society of Endocrinology, the European Society for Paediatric Endocrinology, the Lawson Wilkins Pediatric Endocrine Society and the World Professional Association for Transgender Health (WPATH) as the bodies that commented on drafts (Hembree et al. 2009).

The 2017 revision (Hembree et al., J Clin Endocrinol Metab 2017;102(11):3869–3903) was written by a task force of nine experts and a methodologist. Its listed co-sponsors are the American Association of Clinical Endocrinologists, American Society of Andrology, European Society for Pediatric Endocrinology, European Society of Endocrinology, Pediatric Endocrine Society, and WPATH (Hembree et al. 2017). Its core adolescent pathway:

• No puberty blockers or hormones before puberty (rec. 1.4).
• GnRH agonists ("puberty blockers") from Tanner stage 2, the first physical signs of puberty (recs. 2.1–2.3).
• Cross-sex hormones once a team confirms persistence and capacity to consent, "which most adolescents have by age 16 years" (rec. 2.4), with "compelling reasons" allowing earlier starts (rec. 2.5).
• Genital surgery involving gonadectomy or hysterectomy from 18 (rec. 5.5). For mastectomy, "There is insufficient evidence to recommend a specific age requirement" (rec. 5.6).

The guideline's own disclaimer says its recommendations "cannot guarantee any specific outcome, nor do they establish a standard of care." This matters later, because the Society and others have repeatedly described it as exactly that.

The WPATH connection

Co-sponsorship and shared criteria

WPATH did more than endorse the guideline. It co-sponsored both versions and, as a co-sponsor, reviewed and commented on drafts. The eligibility criteria the guideline uses for adolescents (Table 5) and adults (Table 4) are each printed with the line "Reproduced from World Professional Association for Transgender Health". In other words, the core gatekeeping criteria were taken from WPATH's Standards of Care version 7 (SOC7).

The traffic runs both ways. WPATH's SOC7 (2011/2012) cites "Hembree et al., 2009" as its source for the staging of adolescent interventions and for GnRH analogues being "the preferred treatment". SOC8, the 2022 eighth version (Coleman et al. 2022), cites the 2017 Endocrine guideline dozens of times. The University of York team that appraised guidelines for the Cass Review called this "problematic circularity, 'with WPATH adopting Endocrine Society recommendations in its own guideline and acting as a cosponsor for and providing input on drafts of the Endocrine Society guideline'" (as quoted in the US Department of Health and Human Services (HHS) evidence review, HHS 2025, citing Taylor et al. 2024a).

For the WPATH side of this story, including the court-released documents on age limits and evidence reviews, see the WPATH Files.

Shared authors

The table lists only roles confirmed in primary sources: WPATH's own history and board pages, the SOC7 revision committee list, the SOC8 author list (PubMed) and WPATH's SOC8 contributor biographies. "None found" means we found no WPATH role, not that none exists.

Four of the ten 2017 authors (Rosenthal, Safer, Tangpricha, T'Sjoen) then helped write SOC8's hormone chapter, with Tangpricha as its lead. The HHS review states that most of the 2009 authors "were also prominent WPATH members and leaders". It adds that the 2017 update "further cemented the relationship with WPATH through common authorship" (HHS 2025).

The guideline's "Financial Disclosures of the Task Force" section lists no WPATH, EPATH or USPATH role for any author. Every author except Rosenthal, Hannema and Tangpricha is recorded as "significant financial interest or leadership position: none declared". T'Sjoen's EPATH presidency (from 2015) falls inside the stated one-year disclosure window. It is not clear whether the Society's form expected unpaid roles in professional associations to be listed. Even so, a reader of the 2017 guideline could not learn from its disclosures that the panel overlapped heavily with a co-sponsor's leadership.

How courts and insurers treat the two together

Because the two documents agree, courts, insurers and medical associations have often cited them together as "the" standards. The medical associations' amicus brief in United States v. Skrmetti (the US Supreme Court case over Tennessee's ban on youth gender medicine), which the Endocrine Society joined (filed 3 September 2024), described them as the "professionally accepted medical guidelines" for adolescents. In his concurrence in the June 2025 ruling, Justice Thomas pointed to the Cass Review's finding that guidelines, "including not only the WPATH 2022 Guidelines, but also those from groups like the Endocrine Society", cited weak evidence to recommend treatment or based recommendations on "other guidelines" (United States v. Skrmetti, 605 U.S. (2025), Thomas J., concurring).

Insurers do the same. UnitedHealthcare's commercial Gender Dysphoria Treatment policy, effective 1 October 2026, grounds its definitions in "(Coleman et al., 2022; Hembree et al., 2017)". The same policy summarises the York finding that the two guidelines "are linked through cosponsorship and lack transparency and developmental rigor" (UnitedHealthcare 2026). So the guideline sets coverage criteria even in a policy that acknowledges its independent appraisal was poor.

Evidence quality

The guideline's own GRADE ratings

The 2017 guideline uses GRADE, a system that rates the quality of evidence (high, moderate, low, very low) separately from the strength of a recommendation. "We recommend" (1) is strong and "we suggest" (2) is weak. Its own ratings for children and adolescents are:

No adolescent recommendation rests on evidence better than "low". Four are nonetheless strong. Under GRADE, a strong recommendation on low or very low evidence is meant to be a rare exception with an explicit rationale. The guideline does give a values statement for blockers: the recommendations "place a high value on avoiding an unsatisfactory physical outcome when secondary sex characteristics have become manifest and irreversible, a higher value on psychological well-being, and a lower value on avoiding potential harm from early pubertal suppression."

In the evidence section for recs. 2.1–2.2, the guideline states: "Pubertal suppression is fully reversible". For the claim that blockers improve psychological functioning, it cites a single study (de Vries et al. 2011). One of that study's authors, Cohen-Kettenis, was also a guideline author. For the long-term effects of blockers, see puberty blockers.

What the commissioned reviews covered, and what they didn't

The task force "commissioned two systematic reviews", both from Murad's Mayo Clinic team, with literature searches ending 7 April 2015. One covered sex steroids and lipids or cardiovascular outcomes (Maraka et al. 2017). The other covered bone health (Singh-Ospina et al. 2017). Both rated their evidence low. Neither examined whether puberty blockers or hormones reduce gender dysphoria or improve mental health in adolescents. That is the central question the adolescent recommendations depend on.

The HHS review notes that "none of the systematic reviews that supported the ES guidelines were based on outcomes for children or adolescents". It adds that the one adolescent study included, Klink et al. (2015), found bone density "below their pretreatment potential" after blockers and hormones (HHS 2025).

Gordon Guyatt, a co-developer of GRADE, told The BMJ in 2023 that he found "serious problems" with the guideline. He noted that its reviews "didn't look at the effect of the interventions on gender dysphoria itself, arguably 'the most important outcome.'" He said "GRADE discourages strong recommendations with low or very low quality evidence except under very specific circumstances." In an emailed response, the Society "referenced the GRADE system's five exceptions, but did not specify which it was applying" (Block 2023).

Independent appraisals

• York / Cass Review (2024). The University of York scored 23 guidelines with the AGREE II tool, a standard instrument for rating how rigorously a guideline was developed. It found that WPATH and the Endocrine Society "formed the basis for most other guidance". It concluded that most guidance "lacks an independent and evidence-based approach" (Taylor et al. 2024a; Taylor et al. 2024b). The Endocrine Society guideline scored 4 out of 7 overall and was not recommended for implementation. Only the Swedish and Finnish guidelines were. See evidence reviews for the wider picture.
• US HHS review (May 2025, final November 2025). HHS assessed the WPATH, Endocrine Society and American Academy of Pediatrics (AAP) documents "as very low quality". It called the Society's guideline "outdated" and found that it was "not trustworthy and not recommended for implementation" (HHS 2025). The review was commissioned under the Trump administration, and its authors were initially anonymous. Medical associations, including the Endocrine Society, criticised its process.
• The Dutch studies underneath. Abbruzzese, Levine and Mason argue that the two Dutch studies that formed "the foundation and the best available evidence" for youth transition are methodologically flawed. They point to selection of the most successful cases, a reversed questionnaire used to measure "resolution" of dysphoria, and psychotherapy given alongside hormones that confounds the results (Abbruzzese et al. 2023).

The Society's language: "standard of care" and "fully reversible"

The guideline says it does not "establish a standard of care". The Society's public statements have said otherwise. In October 2019, responding to a Texas custody case, it described "The Endocrine Society's Clinical Practice Guideline, which sets the standard of care for transgender individuals" (Endocrine Society 2019).

Its December 2020 position statement described pubertal suppression as "a treatment which is fully reversible". It also asserted "a durable biological element underlying gender identity" (Endocrine Society 2020).

By May 2024 the wording had softened. The guideline "recommends beginning treatment with puberty-delaying medications that are generally reversible" (Endocrine Society 2024). The guideline's own text says no data exist on time to ovulation after prolonged blockade, and none on the time needed for sperm production to resume in this population. For the gap between how these drugs were described and what is known, see informed consent and iatrogenic harm.

Institutional incentives

This section sets out documented incentives only. An incentive is not proof that it changed any recommendation, and nothing here concerns any individual's personal identity.

Ideological and professional incentives

• Advocacy alongside guideline-writing. The Society issues the guideline and also campaigns publicly against restrictions on the care it recommends. It joined the Skrmetti amicus brief in 2024 and the joint statement that called the June 2025 ruling disappointing because it "increases the likelihood that other states will limit or eliminate families' and patients' ability to access medical care" (Endocrine News 2025). Its 2024 statement said "We stand firm in our support of gender-affirming care." An organisation publicly committed to a position in court and in politics has a reputational stake in its guideline being right.
• Co-sponsorship with the main advocacy body in the field. WPATH co-sponsored the guideline, reviewed its drafts and supplied its eligibility tables.
• Authors appraising interventions they deliver or pioneered. Several authors ran or founded clinics providing these treatments, or authored the studies the guideline relies on. The HHS review describes the risk of "panel stacking" ("populating clinical practice guideline development groups with individuals who share a similar position regarding the treatment under consideration, often due to having financial or non-financial conflicts of interest"). It notes that three 2009 authors "were the founders of the Dutch protocol". It also says the Society "recommended PMT [pediatric medical transition] despite not having conducted SRs of evidence for benefits and most risks". The York team likewise found that most guidance "lacks an independent and evidence-based approach".
• Leadership of the revision. HHS notes that the Society adopted the National Academy of Medicine's conflict-of-interest standards in 2022. It argues that Safer's leadership of the revision, given his close association with WPATH, "raises concerns about compliance" with those standards. That is HHS's assessment, not a finding of any rule breach.

Financial incentives

• Declared author conflicts (2017). Rosenthal declared "AbbVie (consultant)" and US National Institutes of Health (NIH) grant funding. AbbVie markets the GnRH agonist Lupron Depot-PED, the leuprolide product used as a puberty blocker, and the testosterone gel AndroGel. Hannema declared lecture or conference payments from Ferring Pharmaceuticals and Pfizer. Tangpricha declared grants from the Cystic Fibrosis Foundation and NIH and a journal editorship. The guideline states that "The Endocrine Society provided the funding for this guideline" and that the task force received no commercial remuneration.
• Industry funding of the Society. AbbVie's own grant reports list payments to the Endocrine Society of $200,000 in educational grants in 2014 (AbbVie 2014) and $54,095 in sponsorships and an educational grant in 2021 (AbbVie 2021). They also list sponsorships of the Pediatric Endocrine Society, a co-sponsor, in 2021–2023 (AbbVie 2023). These reports do not say what the money funded. We found no document tying any of it to the gender guideline.
• Payments to individual authors. A search of the US government's Open Payments general-payments data for 2019–2025 found no records for Safer, Tangpricha or Meyer. For Rosenthal it found one $35.74 food-and-beverage record from AbbVie linked to Lupron Depot in 2024 (CMS Open Payments). Open Payments only covers US physicians and excludes some research funding. Even so, on the documented record the financial ties are modest compared with the professional and ideological ones above.

The Society's defence

The Society's position, and the strongest arguments made for the guideline, deserve a fair hearing:

• It is more cautious than its critics suggest. The guideline recommends nothing medical before puberty, requires a mental-health diagnosis by a qualified professional and a multidisciplinary team, and sets 16 as the usual start for hormones and 18 for genital surgery. The Society calls this "a very conservative approach to care" that "cites more than 260 research studies" (Endocrine Society 2024).
• Low-certainty evidence is common in medicine. GRADE does allow strong recommendations on weak evidence in defined situations. In 2025 Guyatt himself, with McMaster University colleagues, wrote that "It is profoundly misguided to cast health care based on low-certainty evidence as bad care or as care driven by ideology". He called the use of GRADE to justify bans "an unconscionable use of our work" (Mother Jones 2025). His criticism of the guideline's method and his opposition to bans are both on the record.
• On Cass. The Society said the Cass Review "does not contain any new research that would contradict the recommendations made in our Clinical Practice Guideline". Its argument is that York found weak evidence, which the guideline had already acknowledged, rather than evidence of harm.
• On HHS and the FTC. The Society declined to take part in the HHS review, citing an unclear peer-review process. In January 2026 the Federal Trade Commission sent it a civil investigative demand about the 2017 guideline and the 2020 position statement. The Society sued. On 8 May 2026 Chief Judge James Boasberg granted it and WPATH preliminary injunctions, citing "extensive evidence of animus and wafer-thin justifications" (The Advocate 2026). The FTC withdrew its demands to the Society, the AAP and WPATH as of 17 June 2026 (Bloomberg Law 2026). The same day it sued WPATH alone in Texas (FTC 2026). Those are allegations, not findings.

The weakness in the defence is that the critics' main complaints are about method, not politics. Strong recommendations rest on low-quality evidence. No systematic review was done of the outcome that matters most. Authors overlap with a co-sponsor. Each of these can be checked in the guideline itself.

Timeline

What detransitioners report

Detransitioners rarely name the Endocrine Society. They describe endocrinologists, the clinicians whose practice the guideline governs. The accounts below are a self-selected sample from /r/detrans and cannot show how common these experiences are. They do show what the guideline's safeguards (assessment, informed consent, monitoring) looked like from the patient's side when they failed.

When I went to the endocrinologist she just showed me a packet with some symptoms and permanent changes and told me that kaiser used to make people sign it but not anymore and gave the prescription. It's terrible —Lilviolin, detrans female

I was diagnosed with PCOS at 13 years old by my endocrinologist. She told me I had the T levels of an adult male. She still put me on testosterone. Testosterone exacerbated the problems. —crawfishwoman, detrans female

The endocrinologist just kept giving me more testosterone. We never discussed the option of stopping. I would have stopped, but I was afraid that would be dangerous somehow. I was a stupid kid, she was the adult and the doctor. —neongrayjoy, detrans female

The doctor who handled my testosterone prescription told me that I would achieve "maximum masculinization" at 3 years of being on T … and denied that stopping testosterone could cause any health issues, even temporarily (which meant I spent 8 months with no hormones, dealing with constant muscle/joint pain, hot flashes, and suicidality with zero medical oversight). —detransdelphinidae, detrans female

The "fully reversible" framing comes up again and again:

I heard the claim that puberty blockers "have no side effects" and are "100% reversible" everywhere. —Femmeghost99, desisted female

I'm a sophomore boy in highschool with most 8th grade girls being taller than me, my muscles and bones are so extremely weak, and I feel a mile behind every boy in my grade when it comes to development. —Appropriate-Most-969, detrans male

Others point to the lack of any guideline for stopping:

my specialist told me the same thing. she said there are basically no studies or research, and no correct way to stop HRT. —loveincautionn, detrans male

The Society's guideline has no section on stopping hormones or on detransition. See testosterone cessation and estrogen cessation.

The site's own analysis of r/detrans stories shows how often these pathways began early. Among stories with a recorded hormone start age, 252 of 876 began cross-sex hormones at 16 or younger. The 93 stories that mention puberty blockers report a median start age of 14 (detrans.ai stats). These are AI-extracted figures from a self-selected sample, not treatment or detransition rates.

Trans perspectives

Criticism of the guideline does not come only from detransitioners. Some trans commenters see the Endocrine Society's hormone targets as too cautious:

Yeah, I agree. My blood serum levels were 700 - 900 pmol/L during the trial, I got amazing results. —seulgimonster, trans woman (MTF)

Others treat WPATH and Endocrine Society protocols as a conservative baseline and advise patients to push providers toward them:

Research WPATH and understand that their protocols are very conservative. —Good-Ad-3785, trans woman (MTF)

Both camps describe endocrinologists who were poorly informed. Both treat WPATH and the Endocrine Society as one standard. That is the same merging of the two documents that the York team identified.

Revision status

In February 2024 the Society told CNN that it was revising the guideline as a routine update "not prompted by politics", chaired by Safer, with "about three years" until completion (CNN 2024). Its May 2024 statement said the update would "conduct systematic reviews". As of October 2026 we found no published revision, so the 2017 guideline remains the Society's current guidance.

Whether the new version is independent of WPATH will depend on who writes it, which questions its systematic reviews ask, and whether it publishes them. For comparable institutional histories, see the AAP, Sweden's Karolinska and the Tavistock GIDS, or return to the scandals hub. Studies on blockers and hormones are collected in the study archive, and the hormones hub covers each drug's known risks. If you are detransitioning and need support, see the support directory.

References

• Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. (2009). Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 94(9):3132–54. PubMed.
• Hembree WC, Cohen-Kettenis PT, Gooren L, et al. (2017). Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 102(11):3869–3903. journal, PubMed.
• Maraka S, et al. (2017). Sex Steroids and Cardiovascular Outcomes in Transgender Individuals: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab 102(11):3914–3923. PubMed.
• Singh-Ospina N, et al. (2017). Effect of Sex Steroids on the Bone Health of Transgender Individuals: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab 102(11):3904–3913. PubMed.
• de Vries ALC, Steensma TD, Doreleijers TAH, Cohen-Kettenis PT (2011). Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med 8(8):2276–2283. PubMed.
• Coleman E, et al. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. WPATH (revision committee list, p. 111).
• Coleman E, Radix AE, et al. (2022). Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health 23(S1). PubMed.
• WPATH (2021). SOC8 Contributors. PDF.
• WPATH. History and Executive Committee and Board of Directors. history, board.
• Taylor J, Hall R, Heathcote C, et al. (2024a). Clinical guidelines for children and adolescents experiencing gender dysphoria or incongruence: a systematic review of guideline quality (part 1). Arch Dis Child 109(Suppl 2):s65–s72. PubMed.
• Taylor J, Hall R, Heathcote C, et al. (2024b). … a systematic review of recommendations (part 2). Arch Dis Child 109(Suppl 2):s73–s82. PubMed.
• US Department of Health and Human Services (2025). Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices (final, 19 Nov 2025). PDF.
• Block J (2023). Gender dysphoria in young people is rising—and so is professional disagreement. BMJ 380:p382. BMJ.
• Abbruzzese E, Levine SB, Mason JW (2023). The Myth of "Reliable Research" in Pediatric Gender Medicine. J Sex Marital Ther 49(6):673–699. PubMed.
• United States v. Skrmetti, 605 U.S. ___ (2025), Thomas J., concurring. opinion.
• Endocrine Society (2019). Endocrine Society urges policymakers to follow science on transgender health, 28 Oct 2019. Newswise.
• Endocrine Society (2020). Transgender Health: An Endocrine Society Position Statement, 16 Dec 2020. endocrine.org.
• Endocrine Society (2024). Endocrine Society Statement in Support of Gender-Affirming Care, 8 May 2024. endocrine.org.
• Endocrine News (2025). Endocrine Society, Other Medical Organizations Issue Joint Statement on United States v. Skrmetti Decision. Endocrine News.
• Christensen J (2024). Major medical society re-examines clinical guidelines for gender-affirming care. CNN, 26 Feb 2024. CNN.
• Mother Jones (2025). Trans health care "skeptics" lost a key ally (Guyatt interview), Sep 2025. Mother Jones.
• UnitedHealthcare (2026). Gender Dysphoria Treatment, Policy 2026T0580V, effective 1 Oct 2026. PDF.
• AbbVie. Grants and Contributions Reports 2014, 2021, 2023. 2014, 2021, 2023.
• Centers for Medicare & Medicaid Services. Open Payments general payment data 2019–2025. openpaymentsdata.cms.gov.
• The Advocate (2026). Federal judge blocks FTC probes into trans medicine groups, May 2026. The Advocate.
• Bloomberg Law (2026). FTC Refocuses Investigations of Three Transgender Health Groups, 22 Jun 2026. Bloomberg Law.
• Federal Trade Commission (2026). FTC, States Sue World Professional Association for Transgender Health…, 17 Jun 2026. FTC.
• US Senate HELP Committee (2024). Letter from Ranking Member Cassidy to the Endocrine Society re Cass Review and clinical practice guideline, 9 Oct 2024. PDF.
• detrans.ai (2026). Detransition statistics from /r/detrans stories. stats page.