David R. Herz
Bet Rimon 179500, Israel
David@transisrael.org

May 25, 2026

Adv. Inbal Chen
Legal Department
Ministry of Health
39 Yirmiyahu St.
Jerusalem 9446724

cc:
Dr. Hagar Mizrahi, Head of the Medical Division
Prof. Raz Gross, Chair of the National Committee for Gender Adaptation
Adv. Esti Verhaftig-Bass, Head of Digital and Enforcement Division

Re:
Response to your letter of 3 May 2026 (Ref: 201069626) regarding medical treatments for gender adaptation – Urgent call for evidence-based policy review

Dear Adv. Chen,

Thank you for your response of 3 May 2026 concerning medical interventions relating to gender dysphoria and gender transition.

At the outset, it is important to state clearly that individuals experiencing profound distress regarding their sex, body, or identity deserve compassion, dignity, and humane treatment. Genuine psychological suffering exists and should neither be mocked nor dismissed. Yet compassion alone cannot relieve medicine of its obligations to evidence, caution, transparency, and independent scrutiny—particularly where children and adolescents are concerned, and especially where interventions may involve sterilization, sexual dysfunction, lifelong medicalization, and irreversible bodily alteration.

The Ministry's response relies heavily upon appeals to institutional consensus, references to WPATH and other professional bodies, the practices of “Western countries,” and principles of autonomy and informed consent. However, the response does not meaningfully engage with the profound scientific, ethical, and international reconsideration now occurring in this field.

Most importantly, the response does not answer what has become the central question confronting responsible medical systems throughout the Western world:

What evidence, outcomes, or harms would cause the Ministry of Health to reconsider its current assumptions and protocols?

The Sudden Expansion of Cases

This issue is not abstract for me. My own son has been directly affected. So has his girlfriend. A neighbor's daughter. A close friend of my son from high school. Prior to roughly the last decade, I had encountered perhaps one or two transgender-identifying individuals in ordinary life. Now the phenomenon appears everywhere, particularly among adolescents and young adults.

That dramatic increase, over such a short historical period, should itself trigger serious inquiry by any responsible public-health authority.

The Ministry's response does not indicate whether it has studied:

• the sharp rise in adolescent presentations since approximately 2014;
• changes in the sex distribution of presenting patients;
• peer-group clustering;
• social-media and internet influence;
• autism-spectrum prevalence;
• trauma histories;
• psychiatric comorbidities;
• differences between childhood-onset and adolescent-onset presentations;
• or whether multiple distinct phenomena are now being grouped together under a single diagnostic and treatment framework.

The increase itself cannot simply be assumed to reflect previously unmet medical need. Responsible medicine requires investigation into causation, not merely accommodation of outcomes.

The Ministry's response also does not address a question increasingly raised internationally by clinicians, researchers, parents, and even some within the LGB community itself:

How many adolescents presently identifying as transgender might, under earlier clinical frameworks, have otherwise matured into gay or lesbian adults without medical intervention?

Given the dramatic increase in adolescent-onset presentations—particularly among young females—this question cannot simply be dismissed as politically inconvenient.

The International Landscape Is No Longer Settled

The Ministry's letter presents the matter as though a stable international consensus presently exists regarding pediatric gender medicine. That is no longer the case.

Over the last several years, substantial reassessment has occurred throughout the Western world. England commissioned the Cass Review. Finland, Sweden, Norway, and other European countries have moved toward increased caution and restriction regarding medical transition pathways for minors. Within the United States, numerous states have restricted or prohibited puberty blockers and cross-sex hormones for minors, while federal agencies and independent reviewers have increasingly questioned the quality of the underlying evidence base.

The legal, ethical, and scientific landscape is changing rapidly.

Yet Israel appears to continue relying substantially upon a framework developed in 2014, before much of the current international evidence review and controversy emerged.

This raises an obvious and necessary question: has the Ministry of Health conducted or commissioned any truly independent Israeli review comparable to the major reassessments now occurring internationally?

If such a review exists, it should be made public.

If no such review exists, the basis upon which the Ministry continues to characterize these interventions as established care deserves serious clarification.

Erosion of Original Safeguards

Much of modern pediatric gender medicine traces its intellectual and clinical origins to the original Dutch protocols, which were narrow, cautious, and highly selective. Those early protocols involved carefully screened patients, extensive psychological evaluation, tightly controlled clinical conditions, and relatively limited cohorts.

Over time, however, many of the original safeguards appear to have weakened or disappeared as the treatment model expanded dramatically in both scale and scope.

Questions therefore arise as to whether the Ministry has independently examined:

• whether present-day patient populations resemble the original Dutch cohorts upon which much subsequent practice was justified;
• whether adolescent-onset presentations differ materially from childhood-onset cases;
• whether significant psychiatric complexity is receiving adequate evaluation;
• and whether exploratory psychotherapy and developmental assessment have increasingly been displaced by affirmation-based approaches.

These are not political questions. They are questions of medical ethics and evidentiary integrity.

Independent Review and Structural Safeguards

The Ministry's 2014 circular establishes a committee structure that includes specialists already professionally involved in these interventions. No allegation of bad faith is intended toward any individual clinician, many of whom are undoubtedly motivated by sincere concern for suffering patients.

Nevertheless, contested areas of medicine require meaningful safeguards to ensure genuine independence of review.

A medical framework should not be evaluated exclusively by individuals already professionally, reputationally, or ideologically invested in its continuation and expansion. Independent scrutiny is not hostility toward medicine; it is a basic safeguard of scientific integrity and public trust.

History repeatedly demonstrates that sincere compassion, untethered from caution and disciplined skepticism, can be redirected toward harmful ends. Precisely because vulnerable people deserve compassion, medicine must remain capable of asking difficult questions—especially where children, identity, fertility, sexuality, and irreversible interventions are concerned.

The Problem of Circular Standards

The Ministry's response relies substantially upon the authority of organizations such as WPATH and related professional bodies. Yet increasingly serious questions have emerged internationally regarding whether these standards represent genuinely independent scientific consensus or, instead, a largely self-referential system of professional validation.

Over time, an ecosystem appears to have developed in which:

• activist organizations influence standards bodies;
• standards bodies influence hospitals and professional associations;
• professional associations influence regulators and courts;
• medical schools and clinicians are trained according to those same standards;
• and the resulting institutional agreement is then presented as independent corroboration of the underlying framework.

Such a process can create the appearance of overwhelming consensus even where the underlying evidence base remains weak, uncertain, contested, or methodologically limited.

This concern is particularly important in the case of WPATH because many of the standards and recommendations increasingly relied upon internationally appear to rest upon low-quality evidence, expert opinion, and internally reinforcing assumptions rather than rigorous long-term outcome data.

Recent disclosures, controversies, and international reviews have only intensified these concerns.

This does not mean that every clinician, researcher, or institution involved acts in bad faith. Many are undoubtedly motivated by sincere concern for suffering patients. But sincerity alone cannot substitute for scientific rigor, and institutional repetition alone cannot transform uncertain evidence into settled medical fact.

Where irreversible interventions involving children are concerned, the existence of a self-reinforcing professional consensus should invite greater scrutiny—not less.

For precisely that reason, independent review becomes indispensable.

The Ministry's response, however, appears to assume the trustworthiness of these standards rather than demonstrating why such trust remains justified in light of the growing international controversy surrounding them.

Evidence, Experimental Treatment, and the Precautionary Principle

Where:

• long-term evidence remains limited;
• interventions may be irreversible;
• patients are minors;
• outcomes remain disputed;
• and international standards are rapidly evolving,

a responsible medical system cannot simply presume settled scientific certainty.

Under such circumstances, the ethical burden shifts toward caution rather than acceleration.

This concern becomes especially acute where drugs are used outside their original approved purposes, long-term developmental consequences remain uncertain, and the affected population consists largely of psychologically vulnerable adolescents undergoing profound neurological, emotional, and sexual maturation.

Particularly troubling is the continued conceptual expansion of these interventions into areas that increasingly appear detached from the original rationale of “cross-sex identification.”

The emergence of requests for so-called “nullification” procedures, including forms of genital removal intended not to approximate the opposite sex but rather to eliminate sexual anatomy altogether, raises serious questions about whether the governing framework remains medically coherent.

Such developments appear difficult to reconcile with the original claim that these interventions are grounded primarily in a stable and persistent identification with the opposite sex.

At minimum, they suggest the possibility that broader psychological, social, ideological, or identity-related dynamics may now be operating within the same clinical space.

That possibility alone warrants caution, independent review, and far more rigorous long-term study.

The appropriate response to uncertainty is not indifference toward suffering patients. It is humility, restraint, and rigorous long-term evaluation.

Brain Development, Fertility, and Informed Consent

The Ministry's response relies heavily upon principles of autonomy and informed consent. Yet informed consent possesses meaningful ethical value only where uncertainty, risks, alternatives, and limitations are fully disclosed and genuinely understood.

The Ministry's own 2014 consent form acknowledges that surgical interventions may eliminate the possibility of natural parenthood and do not guarantee sexual satisfaction. These are not minor or incidental consequences.

Moreover, adolescence is not a static condition. Neurological development continues well into the twenties. Puberty is not merely cosmetic; it is a major neuroendocrine developmental process affecting emotional maturation, cognition, sexuality, fertility, identity consolidation, and the developing brain itself.

Clarification is therefore respectfully requested regarding:

• which drugs are presently utilized in Israel for puberty suppression and cross-sex intervention in minors;
• whether such usage is formally approved for these purposes;
• what disclosures are made concerning off-label use;
• what evidence the Ministry relies upon concerning long-term neurological and developmental outcomes;
• and whether patients and families are explicitly informed regarding the present uncertainty surrounding many long-term outcomes.

Outcome Tracking and Accountability

The Ministry's response does not indicate whether comprehensive long-term outcome tracking currently exists within Israel.

Does the Ministry systematically collect and publish data concerning:

• rates of referral;
• psychiatric comorbidities;
• autism-spectrum prevalence;
• use of puberty blockers and cross-sex hormones;
• fertility outcomes;
• detransition;
• regret;
• sexual dysfunction;
• long-term psychological outcomes;
• suicidality before and after intervention;
• and eventual surgical intervention?

Absent rigorous longitudinal tracking, it becomes difficult to understand how any medical authority can confidently assure the public that current protocols are safe, effective, and justified over the long term.

A medical system must remain capable not only of counting perceived successes, but also of identifying harms.

This leads to another unavoidable question: what level of harm would trigger reconsideration?

What rates of regret, infertility, psychiatric deterioration, sexual dysfunction, or detransition would cause the Ministry to pause, reevaluate, or restrict these interventions for minors?

No medical framework should be exempt from the obligation of self-correction.

A Debate Concerning Ethics and Safeguarding

Concern regarding current pediatric transition practices no longer originates solely from religious communities, conservatives, or political opponents. Increasingly, criticism is emerging from clinicians, detransitioners, feminists, parents, lesbians and gay men, former supporters of the affirmative model, and individuals who once participated directly in these systems.

This is significant because it demonstrates that the present debate cannot honestly be reduced to “compassion versus hatred.”

Rather, it is a dispute concerning evidence, ethics, developmental psychology, safeguarding, and the appropriate limits of irreversible medical intervention in vulnerable populations.

Particularly noteworthy is the growing discomfort expressed by some within the lesbian and gay community itself. In several Western countries, activists and advocacy organizations have been accused of pressuring lesbians and gay men to redefine long-standing concepts of sexual orientation, bodily boundaries, and same-sex attraction in ways that many find coercive or psychologically destabilizing.

Reports and public controversies in the United Kingdom and elsewhere have included allegations that same-sex attracted individuals were encouraged to become more accepting of sexual relationships involving individuals who identify as the opposite sex while retaining intact biological anatomy. Other accounts have described a dismissive attitude toward the possibility that a substantial number of gender-distressed youth may otherwise have matured into gay or lesbian adults.

Whether every such allegation proves accurate is ultimately less important than the broader reality they reveal: the current movement increasingly extends beyond compassion for dysphoric individuals and into efforts to redefine sex, sexual orientation, bodily reality, and even the developmental boundaries of childhood itself.

This expansion should concern any serious medical authority.

Children deserve extraordinary caution precisely because they are children.

Requested Clarifications and Actions

In light of the foregoing, the following clarifications and actions are respectfully requested:

1. Publication of any independent Israeli evidence review concerning pediatric gender medicine;
2. Commissioning of such a review if none presently exists;
3. Publication of aggregate Israeli treatment and outcome data;
4. Establishment of mandatory long-term follow-up and outcome tracking;
5. Clarification regarding the use of off-label medications;
6. Reevaluation of informed-consent procedures for minors and families;
7. Inclusion of broader professional perspectives within future review processes;
8. Clarification regarding what thresholds of harm would trigger policy reconsideration;
9. Consideration of whether irreversible medical interventions for minors should be paused or substantially restricted pending stronger evidence.

Conclusion

No doubt exists that many individuals working in this field are motivated by sincere compassion for suffering patients. Yet good intentions alone cannot substitute for evidence, and compassionate motives do not guarantee sound outcomes.

Modern societies have repeatedly learned—often painfully—that vulnerable populations can become the testing ground for ideas whose harms are not fully understood until years later.

The strongest version of compassion is not blind affirmation. It is the willingness to ask difficult questions before irreversible harm occurs.

The duty of medicine is not merely to affirm distress. It is to seek truth carefully enough to avoid compounding suffering with irreversible harm.

Israel should not wait for its own reckoning before asking whether greater caution, humility, transparency, and independent review are urgently required.

Respectfully,

David R. Herz