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

23 June 2026

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

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 letter of 3 May 2026 and for the reference to the 2014 Director-General’s Circular (No. 16/2014). I appreciate your response. However, deep concern arises from the fact that the 2014 guidance, which remains the foundation of current Israeli policy, rests on remarkably weak evidence.

Major 2024 reports and subsequent analyses have shone a bright light on the scale of the medical disaster that has resulted from this model of care. When the occurrence of a condition or “disease” explodes by hundreds or even thousands of percent in such a short time, it is only responsible to pause, investigate the underlying causes (including social contagion), and refrain from proceeding with what is increasingly recognized as tragically indefensible invasive and irreversible medical intervention.¹

What is the process when it becomes obvious we have done something wrong? How much damage must occur—how many children and young adults must be medicalized, mutilated, and left disfigured—before the Ministry calls for a pause to study the matter? There must be emergency powers available; what exactly must be shown to trigger them? What internal mechanisms exist within the Ministry for updating clinical guidelines when the “chain of trust” in medical care has been broken (as evidenced by systematic reviews and leaks), and how can concerned citizens and experts help activate them? As I suggest below, even if such a mechanism has never been used before, this is precisely the case that demands urgent emergency action to end this damaging line of “therapy.”

I assume it is our shared goal to ensure that Israeli policymakers and the public have access to the best available evidence so that we do not inadvertently cause harm to our children and young adults. I also have a very personal stake in this. I want to stop the damage being done to my son, his girlfriend, a friend’s daughter, and so many others who I don’t know. I want to end the family trauma this causes. I want to see our children grow up healthy in the bodies G-d meant for them.

I have spent twenty months trying to reach the people responsible for protecting our children—yours, mine, all of them. This is not an abstraction. Behind every case file is a family: parents who trusted the system, siblings who watch a brother or sister disappear into a medical pathway that was supposed to help, mothers and fathers whose own health buckles under the weight of what is being done to their children in the name of medicine.

Much of my effort has been directed at the Knesset. There, committee offices redirect me to committee heads who don’t answer. Ministers post on social media about child welfare while ignoring letters about actual children being harmed. Since October 2024 I have also written to this ministry — to the Minister, to the Director General, and to your department — and your response is the first substantive reply I have received.

The response reads essentially as a bureaucratic statement that we have a process, the process is sound, and therefore no further action is required. What is difficult to understand is how the Ministry — whose entire mandate is the health of Israelis — can look at the conclusions reached by Sweden, Finland, Norway, and Britain, and at what is occurring in clinics across this country, yet find it easier to issue a legal disclaimer than to ask a single hard question about the current policy. There is no assumption of bad faith on the part of any individual. The concern is institutional: the response does not appear to engage with the weight of the international evidence now before us.

The current Israeli framework treats puberty blockers, cross-sex hormones, and related interventions for gender dysphoria as standard care despite remarkably weak evidence of long-term benefit and well-documented risks of harm. These treatments must be removed entirely from the national health basket and reclassified as experimental. They should be available only as part of appropriately structured clinical research protocols that meet full ethical, safety, and long-term outcome-tracking standards. Medicalization of gender dysphoria before completion of brain development—which current science indicates continues well into the mid-20s (and in some respects into the early 30s), with cross-sex hormones and puberty blockers interfering with normal neurological and pubertal processes—warrants particular caution.²

The 2014 Circular is Outdated, Structurally Problematic, and Insufficient for Experimental Treatments

The 2014 circular seems to represent an attempt to regulate adult surgeries and establish multidisciplinary oversight. However, it does not justify itself, and there is an increasing awareness that the state of the research was such that it never could have. This was laid bare in the Cass Review (2024), the WPATH Files (2024), and the major European systematic evidence reviews that have shown the landscape for what it truly is since then.³

The structural design of the Circular—particularly the composition and approval process of the national multidisciplinary committee—almost certainly places activists rather than disinterested surgeons and practitioners in key decision-making roles.

Moreover, the informed-consent form attached to the Circular is inadequate for experimental interventions. It lacks mandatory independent ethics review (IRB/Helsinki principles), long-term outcome tracking, and other safeguards required under the Israeli Patient Rights Law 1996 and the Ministry’s own research protocols for human subjects, especially youth.

Given the documented dramatic rise in incidence—thousands of percent in short timeframes at Israeli clinics⁴—the question arises: what specific mechanisms does the Ministry use to monitor and address potential social contagion, including the role of social media and peer influence?

Critiques of WPATH, the Affirmative Model, and the Claim of International Consensus

Your letter treats WPATH as an authoritative source. Unfortunately, WPATH’s Standards of Care Version 8 (SOC8) rely on what has been described as a “circular web of authority” or “citation cartel.” WPATH guidelines are cited by other organizations (e.g., the Endocrine Society), which are then cited back by WPATH, creating an illusion of consensus despite remarkably weak underlying evidence. This exact concern was highlighted in the Cass Review and the accompanying systematic reviews:

“The circularity of this approach may explain why there has been an apparent consensus on key areas of practice despite the evidence being poor.”⁵

Taylor et al. (2024), in their systematic review of guideline quality published in Archives of Disease in Childhood, and the independent AGREE II appraisal of SOC8 by Zhang et al. (2026) in Archives of Sexual Behavior, both scored WPATH’s guidelines poorly on rigor of development, editorial independence, and applicability.⁶ Court documents and analyses by the Society for Evidence-Based Gender Medicine (SEGM) further document WPATH’s interference in independent systematic reviews.

The Cass Review and the European systematic reviews (UK, Sweden, Finland, and Norway) are clear: puberty blockers show no reliable long-term mental-health benefit, lead to near 100% progression of patients to cross-sex hormones, and carry significant risks including infertility, sexual dysfunction, bone-density loss, and cardiovascular issues.⁷ We are also seeing a rapid adolescent-onset surge (especially among natal females), with over-representation of autism, ADHD, and same-sex attraction—many of whom would likely resolve naturally without medicalization.

While your letter notes that many Western countries and states continue to support these treatments, history demonstrates that majority medical consensus has been wrong before—sometimes with tragic consequences. Widely endorsed practices later abandoned due to evidence of harm include: prefrontal lobotomies for psychiatric disorders (tens of thousands performed, Nobel Prize awarded in 1949); thalidomide for morning sickness (over 10,000 children born with severe birth defects in the 1950s–60s); diethylstilbestrol (DES) for miscarriage prevention (cancer in offspring); insulin coma therapy for schizophrenia; overly aggressive radical Halsted mastectomies for breast cancer; routine episiotomies; and early hormone-replacement-therapy regimens later overturned by rigorous trials.

Several leading European nations have already moved away from the affirmative model: the UK (Cass Review → indefinite ban on routine puberty blockers for minors), Sweden, Finland, and Norway have sharply restricted these interventions for youth, prioritizing psychotherapy and limiting medicalization to exceptional cases or research settings. The Netherlands—birthplace of the original Dutch Protocol—has also initiated a parliamentary-mandated independent review of puberty blockers and is facing growing professional calls to revise its guidelines.⁸ Major reversals have also occurred in the United States, where more than 25 states have enacted laws or regulations restricting or banning puberty blockers, cross-sex hormones, and surgeries for minors. Even the American Society of Plastic Surgeons (ASPS) has recommended that gender-related surgeries for minors be delayed until at least age 19 due to insufficient evidence, and the American Medical Association (AMA) has similarly agreed that surgical interventions in minors should generally be deferred until adulthood.⁹ Growing numbers of professional organizations and even LGB groups are publicly questioning rapid medicalization. Regardless, it is the responsibility of the Ministry to follow the best available evidence, not shifting majorities.

The Situation in Israel – A Documented Growth Industry, Costs, Transparency, and Ethical Failures

I welcome the confirmation that no genital surgeries are performed on minors under 18. However, puberty blockers and cross-sex hormones already constitute medicalization with lifelong irreversible consequences.

Of great concern is how these treatments entered routine public funding in the first place. While gender-reassignment surgeries were explicitly added to the Health Basket in 1986 (and updated in the 2014 circular), hormone therapy and puberty blockers appear to have been integrated through off-label use of drugs already listed in the basket for other indications (e.g., precocious puberty). There is no public record of the annual Health Basket Committee ever conducting a formal evidence review, safety analysis, or cost-effectiveness determination specifically for the indication of gender dysphoria. This stands in stark contrast to the rigorous process required for virtually every other medication or technology added to the basket. The only recent gender-specific addition was voice therapy in 2022. In short, these interventions appear to have bypassed the standard evidentiary gatekeeping that protects the integrity of the national health basket.¹⁰

Israel has seen an 11-fold increase in pediatric gender-dysphoria referrals since 2013.¹¹ Organizations such as Maavarim (maavarim.org/community-activities) have grown into major funded NGOs supporting thousands of cases annually, while the publicly shared directory of “trans-friendly” professionals demonstrates expanding clinical infrastructure across the country. These trends, combined with widespread social-media access, underscore the urgent need for vigilant monitoring of social contagion.

Health funds do not publish comprehensive public data on numbers, ages, comorbidities, desistance/detransition rates, or total system costs. Lifetime per-patient costs (based on available data) represent a significant and growing public burden.

Growing Professional and LGB Community Opposition Worldwide

While some international bodies continue to reference the affirmative model, a rapidly growing number of medical professionals, researchers, and organizations—including prominent voices from within the lesbian, gay, and bisexual (LGB) community—are publicly opposing the rapid medicalization of gender-dysphoric youth.

Leading professional groups include the Society for Evidence-Based Gender Medicine (SEGM),¹² an international network of clinicians and researchers dedicated to evidence-based care; Genspect,¹³ an alliance of professionals, parents, and detransitioners advocating for high-quality, non-medicalized approaches; and Therapy First, which prioritizes exploratory psychotherapy over hormonal or surgical interventions.

This broadening dissent demonstrates that the affirmative model is facing increasing scrutiny from within the very communities once assumed to be its strongest allies, reinforcing the urgent need for an independent Israeli evidence review.

Specific Requests for Explanation and Action

Given the evidence and concerns set forth above, please explain why the Ministry is not currently pursuing the following (or provide the current status and timeline if any steps are already underway):

1. Immediate moratorium on puberty blockers and cross-sex hormones pending independent review.
2. Commission of an independent, non-WPATH-influenced systematic evidence review (modeled on Cass) by Israeli experts in psychiatry, endocrinology, pediatrics, and medical ethics.
3. Mandatory collection of data and public annual reporting by all health funds and clinics on referrals, treatments, off-label drug use in this area, comorbidities, desistance/detransition, and long-term outcomes.
4. Shift to an exploratory, therapy-first, non-medicalized approach with rigorous differential diagnosis for comorbidities and social influences.
5. Urgent update or replacement of the 2014 circular with evidence-based safeguards.
6. Classification of these interventions as experimental, with full research protocols (IRB approval, long-term tracking, etc.).
7. Public statement acknowledging the international evidence shift and committing to child/youth protection.
8. A formal review of how puberty blockers and cross-sex hormones for gender dysphoria were incorporated into the Health Basket without the standard evidence-based process applied to other treatments, and confirmation that they will be removed from routine basket funding and made available only through properly structured experimental protocols.

Though I am not currently in Israel, I remain available to meet (virtually or in person upon my return). I continue to keep abreast of developments and regularly update transisrael.org to reflect the latest information and data. For further discussion of these issues, please visit transisrael.org. Protecting our children and youth from low-evidence, experimental interventions is a fundamental public-health and human-rights responsibility. I hope the Ministry will choose evidence-based caution and leadership rather than continue with an outdated framework.

While I have assembled key international evidence, systematic reviews, and the Israeli data currently available in the public domain on transisrael.org, there is value to a more comprehensive, Ministry-led review of Israeli clinic data and outcomes. I am prepared to work directly with the Ministry to develop a fuller, Israel-specific dossier for your consideration.

At the same time, the strength of the international evidence — particularly the Cass Review and the U.S. Department of Health and Human Services (HHS) Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices (November 2025), alongside the systematic reviews that led to policy changes in the UK, Sweden, Finland, and Norway — is already sufficient to support prompt precautionary action while any additional data collection and analysis proceeds.

Thank you for your attention to this critical matter. I look forward to your substantive reply.

Yours sincerely,

David R. Herz

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