HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: CS/CS/HB 1421 Gender Clinical Interventions
SPONSOR(S): Health & Human Services Committee, Healthcare Regulation Subcommittee, Fine and others
TIED BILLS: IDEN./SIM. BILLS:
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY CHIEF
1) Healthcare Regulation Subcommittee 12 Y, 5 N, As CS McElroy McElroy
2) Health & Human Services Committee 15 Y, 6 N, As CS McElroy Calamas
SUMMARY ANALYSIS
Gender dysphoria is a behavioral health disorder diagnosable by a health care practitioner. The American
Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders (DSM) classification of gender
dysphoria denote a “marked incongruence between one’s experienced/expressed gender and assigned
gender, of at least six months’ duration” and manifestation of sub-criteria that differs based on age. Little is
known about the cause of gender dysphoria and the marked increase in minors seeking treatment.
Approximately 80% of prepubertal children diagnosed with gender dysphoria do not remain gender dysphoric
or gender incongruent after puberty, but there is no method to distinguish those for whom gender identity
issues may persist into adulthood.
CS/CS/HB 1421 regulates gender clinical interventions provided or performed for the purpose of affirming a
person’s perceived gender, including surgical and hormonal therapies and treatments. The bill prohibits health
care practitioners from providing gender clinical interventions to minors, with exceptions. The bill prohibits all
healthcare practitioners, except Florida-licensed physicians or a physician employed by the Federal
Government, from providing gender clinical interventions to adults. A physician must obtain written informed
consent on a form adopted by the Board of Medicine or Board of Osteopathic Medicine, as applicable, each
time the physician provides gender clinical interventions.
The bill requires the Department of Health (DOH), or the applicable board, to revoke the license of a physician
who violates any of the preceding requirements and imposes criminal penalties for certain violations. The bill
also provides conscience protection for practitioners or other employees who refuse to participate in providing
gender clinical interventions, prohibiting licensure discipline and any other type of recriminatory action against
them.
The bill creates a civil cause of action for injuries and wrongful death caused by gender clinical interventions.
The bill prohibits the use of funds by a government entity for gender clinical interventions and prohibits
insurance companies from providing coverage for such treatments.
The bill prohibits DOH from changing sex on birth certificates for gender identity changes, with exceptions. The
bill establishes requirements for a health care practitioner to request a change to a birth certificate and
expressly prohibits changes based upon a person’s perception of gender. A health care practitioner who
makes a misrepresentation or provides fraudulent evidence in such a request is subject to licensure discipline.
The bill also authorizes a court to modify or stay a child custody determination to protect a c hild from being
subjected to gender clinical interventions in another state.
The bill has no fiscal impact on state or local government.
The bill provides an effective date of July 1, 2023.
This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives .
STORAGE NAME: h1421d.HHS
DATE: 4/3/2023
FULL ANALYSIS
I. SUBSTANTIVE ANALYSIS
A. EFFECT OF PROPOSED CHANGES:
Background
Gender Dysphoria
Transgender and gender nonconforming are general terms for individuals whose gender identity, role,
or expression differ from their biological sex at birth.1 Gender dysphoria refers to the significant
discomfort or distress felt as a result of the gender incongruency.2
Diagnosis and Prevalence
Gender dysphoria is a behavioral health disorder diagnosable by a health care practitioner. The
American Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders (DSM)
classification of gender dysphoria denote a “marked incongruence between one’s
experienced/expressed gender and assigned3 gender, of at least six months’ duration” and
manifestation of sub-criteria that differs based on age.4
Gender Dysphoria Diagnostic Criteria
For all age groups, diagnosis requires both of the following:
Marked incongruity between birth sex and felt gender identity, present for at least six months’ duration.
Clinically significant distress or impairment in social, school, occupational, or other important areas of
functioning.
For children (under age 13), diagnosis requires at least six of the following:
A strong desire to be or insistence that they are another gender.
A strong preference for dressing in clothing typical of the opposite gender, and in girls, resistance to wearing
typically feminine clothing.
A strong preference for cross-gender roles when playing.
A strong preference for toys, games, and activities typical of another gender.
A strong preference for playmates of another gender.
A strong rejection of toys, games, and activities typical of the gender that matches their birth sex.
A strong dislike of their anatomy.
A strong desire for the primary and/or secondary sex characteristics that match their felt gender identity.
For adolescents (over age 13) and adults, diagnosis requires at least two of the following:
A strong desire to be rid of (or for young adolescents, prevent the development of) their primary and/or
secondary sex characteristics.
A strong desire for the primary and/or secondary sex characteristics that match their felt gender.
A strong desire to be another gender.
A strong desire to be treated like a different gender.
A strong belief that they have the typical feelings and reactions of a different gender.
1 Coleman, E., Radix, A.E., Bouman, W.P., Brown, G.R., de Vries, A.L.C., et al, (2022), Standards of Care for the Health of
Transgender and Gender Diverse People, Version 8, International Journal of Transgender Health, 23(S1), S1-S260.
2 Id.
3 The DSM uses “assigned” to refer to the delivery physician’s assessment and notation of the child’s biological sex, usually based on
external genitalia. See, American Psychiatric Association, Gender Dysphoria, available at, https://www.psychiatry.org/patients -
families/gender-dysphoria (last viewed March 18, 2023).
4 American Psychiatric Association, (2013), Diagnostic and Statistical Manual of Mental Disorders (5 th ed.), Arlington, VA: American
Psychiatric Publishing.
STORAGE NAME: h1421d.HHS PAGE: 2
DATE: 4/3/2023
The number of minors diagnosed with gender dysphoria significantly increased the last five years.5
Previously, the majority of individuals diagnosed with gender dysphoria were males but recently there
has been an increase in diagnosis for females.6
The graph below shows the increase of gender dysphoria diagnosis of minors over the last five years.
This number only includes those whose physicians specify a gender dysphoria diagnosis and whose
treatment was covered by insurance; therefore, the numbers are likely much higher.7
Gender Dysphoria Diagnosis of Minors, U.S., 2017 - 2021
2017
2018
2019
2020
2021
0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000
Little is known about the cause of gender dysphoria and the marked increase in minors seeking
treatment.8 There is currently no method to distinguish those for whom gender identity issues may
persist into adulthood. Approximately 80% of prepubertal children diagnosed with gender dysphoria do
not remain gender dysphoric or gender incongruent after puberty. 9 One research review indicated that
61%-98% of children desist by adulthood.10 These data point to a risk for misdiagnosis.
Comorbidity and Gender Dysphoria Diagnosis
Symptoms of gender dysphoria rarely exist in isolation and are commonly exacerbated by psychosocial
stressors and psychiatric disorders.11 Studies consistently show that individuals referred to treatment
for gender dysphoria have high rates – up to 50% – of behavioral and mental health issues compared
to their non-transgender peers.12 Many minors seek treatment for psychiatric issues prior to having
5 Respaut, R. and Terhune, C, Putting numb ers on the rise in children seeking gender care, Reuters Investigates,
https://www.reuters.com/investigates/special-report/usa-transyouth-data/ (last accessed Feb. 6, 2023).
6
Steensma TD, Cohen-Kettenis PT, Zucker KJ, (2018), Evidence for a change in the sex ratio of children referred for gender dysphoria:
data from the Center of Expertise on Gender Dysphoria in Amsterdam (1988 -2016), J. Sex & Martial Therapy 44(7): 713-5; de Graf NM,
Carmichael P, Steensma TD, Zucker KJ, (2018), Evidence for a change in the sex ratio of children referred for gender dysphori a: data
from the gender identity development service in London (2000 -2017), J Sex Med 15(10).
7 Supra note 5.
8
Cass, H., The Cass Review, Independent review of gender identity services for children and young people: interim report , Feb 2022.
9 Streensma, T, Biemond, R, de Boer, F., Cohen Kettenis, P., (2011), Desisting and persisting gender dysphoria after childhood: a
qualitative follow-up study, Clinical Child Psychology and Psychiatry, 16(4):499-516.
10 Laidlaw, M., Van Meter, Q., Hruz P., Van Mol, A., Malone, W., (2019), Letter to the editor: “endocrine treatment of gender-
dysphoric/gender incongruent persons: an endocrine society clinical practice guideline”, J Clin Endocrinol Metab , 104(3):686–687.
11 Vrouenraets et al., 2015.
12 Frew, T., Watsford, C., and Walker, I., (2021), Gender dysphoria and psychiatric comorbidities in childhood: a systematic review,
Australian Journal of Psychology, 73:3, 255-271; Meybodi, A.M., Hajebi, A., and Jolfaei, A.G., (2014), Psychiatric Axis I Comorbidities
Among Patients with Gender Dysphoria, Psychiatry Journal, vol. 2014, Article ID 971814. See also, Russell D., Hoq, M., Coghill, D.,
Pang, K., Prevalence of Mental Health Prob lems in Transgender Children Aged 9 to 10 Years
in the US, 2018, JAMA July 22, 2022. doi:10.1001/jamanetworkopen.2022.23389 , noting that “by 9 to 10 years of age
transgender children already show increased susceptibility to mental health problems compared with their cisgender peers ”, and calling
for more research on the matter.
STORAGE NAME: h1421d.HHS PAGE: 3
DATE: 4/3/2023
gender identity issues. In a study of minors seeking medical treatment for gender dysphoria, 68% had
their first contact with psychiatric services due to reasons other than gender dysphoria. 13 Mental health
conditions commonly comorbid with gender dysphoria include14:
Anxiety15
Depression16
Eating disorders 17
Suicidality18
Self-harm 19
Autism spectrum disorder, a developmental and neurological disorder, is also a common comorbidity. 20
Adults with gender dysphoria have high rates of childhood trauma compared to non-transgender
individuals. When comparing attachment and complex trauma in gender dysphoric adults, 56% of such
adults experienced four or more forms of childhood trauma compared to 7% in non-transgender
peers.21 These childhood traumas include:22
Neglect
Rejection
Role reversal
Psychological abuse
Physical abuse
Sexual abuse
Domestic violence
Separations
Experts have opined that unaddressed psychiatric issues and unaddressed childhood trauma could
lead to misdiagnosis of gender dysphoria and inappropriate gender transition.23
Treatment for Gender Dysphoria
13 Riittakerttu, K-H., Sumia, M., Tyolajarvi, M., & Lindberg, N., (2015), Two years of gender identity services for minors:
overrepresentation of natal girls with severe problems in adolescent development, Child and Adolescent Psychiatry and Mental Health,
9:9.
14 See, also, Barr, S., Roberts, D., & Thakkar, K, (2021), Psychosis in transgender and gender non -conforming individuals: A review of
the literature and a call for more research, Psychiatry Research, 306:114272. The authors reviewed 10 studies of psychosis prevalence
in transgender individuals, and noted that the higher prevalence may be due to diagnostic bias ; that unique factors specific to
transgender identity and individual history (such as discrimination and oppression, childhood trauma, lack of gender affirmation, lack of
culturally-competent mental health care, and substance abuse) might explain higher prevalence; and that this area should be
researched further.
15 Hold, V., Skagerberg, E., and Dunsford, M., Young people with features of gender dysphoria: Demographics and associated
difficulties, Clin Child Psychol Psychiatry (2014).
16 Id.
17 Pham, A., Eadeh, H., Garrison, M., & Ahrens, K., A Longitudinal Study on Disordered Eating in Transgender and Nonbinary
Adolescents, (2022).
18 Reisner, S., et al, (2015), Mental health youth in care at an adolescent urban community health center: A matched retrospecti ve
cohort study, J Adolesc Health, 56(3): 274-279.
19 Id.
20 See VanderLaan, D.P., et al, (2015), Do children with gender dysphoria have intense/obsessional interests? The Jounral of Sex
Research, 52(2), 213-219; Kallitsounaki, A., Williams, D.M., Autism Spectrum Disorder and Gender Dypshoria/Incongruence. A
systematic Literature Review and Meta-Analysis, J. Autism Dev Disord (2022).
21 Giovanardi, G., Vitelli, R., Maggiora Vergano, C., Fortunato A., Chianura L., Lingiardi V., and Speranza AM., (2018), Attachm ent
Patterns and Complex Trauma in a Sample of Adults Diagnosed with Gender Dysphoria, Front. Psychol, 9:60. The attachment and
complex traumas experienced by those in the study varies among males and females.
22 Id.
23 See Supra note 1. See also Littman, L., (2021), Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition
Who Subsequently Detransitioned; A Survey of 100 Detransitioners, Arch Sex Behav, 50, 3353-3369.
STORAGE NAME: h1421d.HHS PAGE: 4
DATE: 4/3/2023
Treatment of minors with gender dysphoria has evolved. Traditionally, gender identity issues were
treated as a mental illness, with treatment primarily provided through psychotherapy to help patients
become comfortable with their sex at birth.24
In the late 1990’s, treatment began shifting to an “affirmative care model” after physicians in the
Netherlands published a report on positive psychological outcomes for a transgender adolescent
treated with hormones.25 Those physicians suppressed puberty in the early stages followed by cross-
sex hormone therapy starting at age 16. This treatment model became known as the “Dutch Protocol”.
The “Dutch Protocol”, as well as the re-categorization of gender identity issues in the DSM, created a
profound shift in the medically accepted treatment for gender issues. In 2013, the authors of the DSM
replaced the term “gender identity disorder” with “gender dysphoria in children” and “gender dysphoria
in adolescence and adults” to diagnose and treat the distress individuals felt by the incongruency
between their gender identities and their bodies.26The medical community stopped classifying gender
identity issues as a mental illness. The “Dutch Protocol” was subsequently incorporated into the widely
adopted standards of care for the treatment of transgender patients. 27
The treatment goal now focuses on affirming the patient’s gender identity rather than affirming the
gender of the patient’s sex at birth. Treatment for gender dysphoria now primarily addresses the
incongruency with psychotherapy and medical interventions that align the body with the mind, rather
than the mind with the body. This treatment may include:28
Psychotherapy to address the negative impact of gender dysphoria and mental health, which
includes social transitioning to affirm an individual’s felt gender identity, role, and expression.
Puberty blockers to suppress the release of testosterone or estrogen and stop the onset of
secondary sex characteristics.
Cross-sex hormone therapy to feminize or masculinize the body.
Sex reassignment surgery to change primary and/or secondary sex characteristics (e.g.,
breasts/chest, external and/or internal genitalize, facial features, and body contouring).
Concerns with Treatment
Clinicians and academics have raised concerns with the appropriateness of medic al interventions for
minors based on the lack of rigorous scientific research on the issue. Various issues bring the value of
gender treatment research into question; specifically: many lack randomized control trials, use small
sample sizes, and have a medium to high risk of bias due to recruitment design.29 From the perspective
of some clinicians, there a