The Science is Not Settled: An American Skeptic’s View of Trans Care for Youth
Main Article Content
Abstract
Aims: This paper defines the disagreements that have deeply divided American clinicians about the prescription of puberty blockers, cross sex hormones, and various surgeries for trans-identified minors. The basic question is what types of evidence should determine clinical management. The issue has not been resolved. Its attendant cultural controversies have spawned lawsuits on ten separate topics in the United States.
Method: This paper presents the current arguments of the proponents of affirmative care and those of skeptics. These arguments are found in professional literature and in court documents.
Results: Twelve of the most contentious issues are discussed: trustworthiness of the benefits; permanence of a trans identities; biological determinism; ethical priorities; informed consent; impact on suicidality; significance of co-morbidities; autism; processes of evaluation; hegemony of the World Professional Association for Transgender Health; childhood social transition. Despite scientific skepticism, major American medical institutions view these arguments as biased.
Conclusions: Perspectives of patients, parents, sociologists, anthropologists, and spokespersons for moral, religious, social justice, and political considerations contribute to the polarized culture. Court decisions are subtly influenced by these perspectives, but their judgments are based on constitutional interpretations. The recent United States Supreme Court ruling upholding Tennessee’s ban on hormonal and surgical care does not mean that all affirmative care is banned throughout all 50 states. The author’s view is that since outcomes are uncertain, parents, not professionals, should be more widely recognized as key decision makers.
Keywords:
gender dysphoria, evidence-based medicine, controversies, bias
Article Details
How to Cite
LEVINE, Stephen B..
The Science is Not Settled: An American Skeptic’s View of Trans Care for Youth.
Medical Research Archives, [S.l.], v. 13, n. 7, july 2025.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/6715>. Date accessed: 06 dec. 2025.
doi: https://doi.org/10.18103/mra.v13i7.6715.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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6. AMA https://code-medical-ethics.ama-assn.org/principles
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8. McNamara M, Baker K, Connelly K, et al. 2024. An evidence-based critique of the “Cass Review’ on gender-affirming care for adolescent gender dysphoria. Available:
https://web.archive.org/web/20240702100251/https://law.Yale.edu/sites/default/files/documents/integrity-project_Cass-response.pdf
9. Cheung CR, Abbruzzese E, Lockhart E, Maconochie IK, Kingdon CC. Gender medicine and the Cass Review: why medicine and the law make poor bedfellows. Arch Dis Child. 2025;110(4):251-255. Published 2025 Mar 19. doi:10.1136/archdischild-2024-327994
10. Marshall S. May 1, 2025. Attorney General Steve Marshall Announces Victory in Defense of Alabama’s Law Prohibiting Sex-Change Procedures for Minors
11. McDeavitt K, Cohn J, Levine SB. Critiques of the Cass Review: Fact-Checking the Peer-Reviewed and Grey Literature. J Sex Marital Ther. 2025;51 (2):175-199. doi:10.1080/0092623X.2025.2455133
12. Kingdon C, Stingelin-Giles N, Cass H. The Cass Review; Distinguishing Fact from Fiction. Am J Bioeth. 2025;25(6):5-10. doi:10.1080/15265161.2025.250 4397
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21. Roberts CM, Klein DA, Adirim TA, Schvey NA, Hisle-Gorman E. Continuation of Gender-affirming Hormones Among Transgender Adolescents and Adults. J Clin Endocrinol Metab. 2022;107(9):e39 37-e3943. doi:10.1210/clinem/dgac251
22. Levine SB. What is the Purpose of the Initial Psychiatric Evaluation of Minors with Gender Dysphoria. J Sex Marital Ther. 2024;50(6):773-786. doi:10.1080/0092623X.2024.2362774
23. Jorgensen SCJ, Athéa N, Masson C. Puberty Suppression for Pediatric Gender Dysphoria and the Child's Right to an Open Future. Arch Sex Behav. 2024;53(5):1941-1956. doi:10.1007/s10508-024-02850-4
24. Levine SB, Abbruzzese E, Mason JW. Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults. J Sex Marital Ther. 2022;48(7):706-727. doi:10.1080/009 2623X.2022.2046221
25. Drescher J. Informed Consent or Scare Tactics? A Response to Levine et al.'s "Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults". J Sex Marital Ther. 2023;49(1):99-107. doi:10.1080/0092623X.2 022.2080780
26. Cavanaugh T, Hopwood R, Lambert C. Informed Consent in the Medical Care of Transgender and Gender-Nonconforming Patients. AMA J Ethics. 2016;18(11):1147-1155. Published 2016 Nov 1. doi:10.1001/journalofethics.2016.18.11.sect1-1611
27. Parkinson P. Adolescent Gender Dysphoria and the Informed Consent Model of Care. J Law Med. 2021;28(3):734-744.
28. Baxendale S. The impact of suppressing puberty on neuropsychological function: A review. Acta Paediatr. 2024;113(6):1156-1167. doi:10.111 1/apa.17150
29. Nunes-Moreno M, Furniss A, Cortez S, et al. Mental Health Diagnoses and Suicidality Among Transgender Youth in Hospital Settings. LGBT Health. 2025;12(1):20-28. doi:10.1089/lgbt.2023.0394
30. Matouk K, Wald M. Gender-affirming care saves lives. 2022. Available:
https://www.columbiapsychiatry.org/news/gender-affirming-care-saves-lives [Accessed 17 Oct 2023].
31. Ruuska SM, Tuisku K, Holttinen T, Kaltiala R. All-cause and suicide mortalities among adolescents and young adults who contacted specialised gender identity services in Finland in 1996-2019: a register study. BMJ Ment Health. 2024;27(1):e300 940. Published 2024 Feb 17. doi:10.1136/bmjment-2023-300940
32. de Blok CJ, Wiepjes CM, van Velzen DM, et al. Mortality trends over five decades in adult transgender people receiving hormone treatment: a report from the Amsterdam cohort of gender dysphoria. Lancet Diabetes Endocrinol. 2021;9(10): 663-670. doi:10.1016/S2213-8587(21)00185-6
33. Wiepjes CM, den Heijer M, Bremmer MA, et al. Trends in suicide death risk in transgender people: results from the Amsterdam Cohort of Gender Dysphoria study (1972-2017). Acta Psychiatr Scand. 2020;141(6):486-491. doi:10.1111/acps.13164
34. Dhejne C, Lichtenstein P, Boman M, Johansson AL, Långström N, Landén M. Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PLoS One. 2011;6 (2):e16885. Published 2011 Feb 22. doi:10.1371/jo urnal.pone.0016885
35. Edwards-Leeper, L. et al. (2017). Psychological Profile of the First Sample of Transgender Youth Presenting for Medical Intervention in a U.S. Pediatric Gender Center. Psychology of Sexual Orientation and Gender Diversity 2017: 4(3) 374.
36. Chen D, Berona J, Chan YM, et al. Psychosocial Functioning in Transgender Youth after 2 Years of Hormones [published correction appears in N Engl J Med. 2023 Oct 19;389(16):1540. doi: 10.1056/NE JMx230007.]. N Engl J Med. 2023;388(3):240-250. doi:10.1056/NEJMoa2206297
37. Liszewski W, Peebles JK, Yeung H, Arron S. Persons of Nonbinary Gender - Awareness, Visibility, and Health Disparities. N Engl J Med. 2018;379 (25):2391-2393. doi:10.1056/NEJMp1812005
38. D'Angelo R. Supporting autonomy in young people with gender dysphoria: psychotherapy is not conversion therapy. J Med Ethics. 2024;51(1): 3-9. Published 2024 Dec 23. doi:10.1136/jme-2023-109282
39. Turban JL. Potentially Reversible Social Deficits Among Transgender Youth. J Autism Dev Disord. 2018;48(12):4007-4009. doi:10.1007/s10803-018-3603-0
40. Rea HM, Øien RA, Webb SJ, Bansal S, Strang JF, Nordahl-Hansen A. Gender Diversity, Gender Dysphoria/Incongruence, and the Intersection with Autism Spectrum Disorders: An Updated Scoping Review. J Autism Dev Disord. Published online December 4, 2024. doi:10.1007/s10803-024-06650-6
41. Taylor J, Hall R, Heathcote C, Hewitt CE, Langton T, Fraser L. Clinical guidelines for children and adolescents experiencing gender dysphoria or incongruence: a systematic review of recommendations (part 2). Arch Dis Child. 2024;109(Suppl 2):s73-s82. Published 2024 Oct 30. doi:10.1136/archdischild-2023-326500
42. Damiano, M. (2024, December 20). A leader in transgender health explains her concerns about the field. Boston Globe. https://archive.is/HrnIK
43. Sinai J, Sim P. Psychodynamic psychotherapy for gender dysphoria is not conversion therapy. J Can Acad Child Adolesc Psychiatry. 2024;33(2):145-153.
44. Hughes M. The WPATH Files: Pseudoscientific surgical and hormonal experimental treatments of children, adolescents and vulnerable adults. Environmental Progress, March 4, 2024.
45. Health and Human Services. (May 1, 2025). Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices https://opa.hhs.gov/sites/default/files/2025-05/gender-dysphoria-report.pdf
46. Rafferty J; COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH; COMMITTEE ON ADOLESCENCE; SECTION ON LESBIAN, GAY, BISEXUAL, AND TRANSGENDER HEALTH AND WELLNESS. Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents [published correction appears in Pediatrics. 2023 Oct 1;152 (4):e2023063756. doi: 10.1542/peds.2023-063756]. Pediatrics. 2018;142(4):e20182162. doi:10.1542/p eds.2018-2162
47. Cantor JM. Transgender and Gender Diverse Children and Adolescents: Fact-Checking of AAP Policy. J Sex Marital Ther. 2020;46(4):307-313. doi:10.1080/0092623X.2019.1698481
48. Zucker KJ. Debate: Different strokes for different folks. Child Adolesc Ment Health. 2020;25(1):36-37. doi:10.1111/camh.12330
49. McDeavitt K, Cohn J, Kulatunga-Moruzi C. Pediatric Gender Affirming Care is Not Evidence-based. Curr Sex Health Rep. 2025; 17, 12-17. https://doi.org/10.1007/s11930-025-00404-w
50. McDeavitt K, Cohn J, Levine SB. Critiques of the Cass Review: Fact-Checking the Peer-Reviewed and Grey Literature. J Sex Marital Ther. 2025;51 (2):175-199. doi:10.1080/0092623X.2025.2455133
51. United States v. Skrmetti, 605 U.S.___,2025 WL1698785 (June 18, 2025)
52. de Vries AL, McGuire JK, Steensma TD, Wagenaar EC, Doreleijers TA, Cohen-Kettenis PT. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014;134(4):696-704. doi:10.1542/peds.2013-2958
53. Irwig MS. Detransition Among Transgender and Gender-Diverse People-An Increasing and Increasingly Complex Phenomenon. J Clin Endocrinol Metab. 2022;107(10):e4261-e4262. doi:10.1210/cl inem/dgac356
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2. Levine, S. B., Brown, G. R., Coleman, E., Cohen-Kettenis, P. T., Van Maasdam, J., Pfafflin, F., & Schaefer, L. C. (1998, June 15). The Standards of Care for Gender Identity Disorders, Fifth Edition. HBIGDA/WPATH.
3. Coleman, E., Radix, A. E., Bouman, W. P., Brown, G. R., de Vries, A. L. C., Deutsch, M. B., Ettner, R., Fraser, L., Goodman, M., Green, J., Hancock, A. B., Johnson, T. W., Karasic, D. H., Knudson, G. A., Leibowitz, S. F., Meyer-Bahlburg, H. F. L., Monstrey, S. J., Motmans, J., Nahata, L., Nieder, T. O., … Arcelus, J. (2022). Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International journal of transgender health, 23 (Suppl 1), S1–S259. https://doi.org/10.1080/26895269.2022.2100644
4. Block J. Gender dysphoria in young people is rising-and so is professional disagreement. BMJ. 2023;380:382. Published 2023 Feb 23. doi:10.113 6/bmj.p382
5. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336 (7650):924-926. doi:10.1136/bmj.39489.470347.AD
6. AMA https://code-medical-ethics.ama-assn.org/principles
7. Cass, H. (2024). Independent review of gender identity services for children and young people: Final report. Available from: https://cass.independent‐review.uk/home/publications/final‐report/
8. McNamara M, Baker K, Connelly K, et al. 2024. An evidence-based critique of the “Cass Review’ on gender-affirming care for adolescent gender dysphoria. Available:
https://web.archive.org/web/20240702100251/https://law.Yale.edu/sites/default/files/documents/integrity-project_Cass-response.pdf
9. Cheung CR, Abbruzzese E, Lockhart E, Maconochie IK, Kingdon CC. Gender medicine and the Cass Review: why medicine and the law make poor bedfellows. Arch Dis Child. 2025;110(4):251-255. Published 2025 Mar 19. doi:10.1136/archdischild-2024-327994
10. Marshall S. May 1, 2025. Attorney General Steve Marshall Announces Victory in Defense of Alabama’s Law Prohibiting Sex-Change Procedures for Minors
11. McDeavitt K, Cohn J, Levine SB. Critiques of the Cass Review: Fact-Checking the Peer-Reviewed and Grey Literature. J Sex Marital Ther. 2025;51 (2):175-199. doi:10.1080/0092623X.2025.2455133
12. Kingdon C, Stingelin-Giles N, Cass H. The Cass Review; Distinguishing Fact from Fiction. Am J Bioeth. 2025;25(6):5-10. doi:10.1080/15265161.2025.250 4397
13. McNamara M, Lepore C, Alstott A. Protecting Transgender Health and Challenging Science Denialism in Policy. N Engl J Med. 2022;387(21): 1919-1921. doi:10.1056/NEJMp2213085
14. Boe v. Marshall, No. 2:22-Cv-00184: 700-18 (M.D. Ala. October 9, 2024).
15. Expósito-Campos P. A Typology of Gender Detransition and Its Implications for Healthcare Providers. J Sex Marital Ther. 2021;47(3):270-280. doi:10.1080/0092623X.2020.1869126
16. Littman L. Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners. Arch Sex Behav. 2021;50(8):3353-3369. doi:10.1007/s10508-021-02163-w
17. Vandenbussche E. Detransition-Related Needs and Support: A Cross-Sectional Online Survey. J Homosex. 2022;69(9):1602-1620. doi:10.1080/009 18369.2021.1919479
18. Abbruzzese E, Levine SB, Mason JW. The Myth of "Reliable Research" in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies-and research that has followed. J Sex Marital Ther. 2023;49 (6):673-699. doi:10.1080/0092623X.2022.2150346
19. Hall R, Mitchell L, Sachdeva J. Access to care and frequency of detransition among a cohort discharged by a UK national adult gender identity clinic: retrospective case-note review. BJPsych Open. 2021;7(6):e184. Published 2021 Oct 1. doi:10.1192/bjo.2021.1022
20. Boyd I, Hackett T, Bewley S. Care of Transgender Patients: A General Practice Quality Improvement Approach. Healthcare (Basel). 2022; 10(1):121. Published 2022 Jan 7. doi:10.3390/healt hcare10010121
21. Roberts CM, Klein DA, Adirim TA, Schvey NA, Hisle-Gorman E. Continuation of Gender-affirming Hormones Among Transgender Adolescents and Adults. J Clin Endocrinol Metab. 2022;107(9):e39 37-e3943. doi:10.1210/clinem/dgac251
22. Levine SB. What is the Purpose of the Initial Psychiatric Evaluation of Minors with Gender Dysphoria. J Sex Marital Ther. 2024;50(6):773-786. doi:10.1080/0092623X.2024.2362774
23. Jorgensen SCJ, Athéa N, Masson C. Puberty Suppression for Pediatric Gender Dysphoria and the Child's Right to an Open Future. Arch Sex Behav. 2024;53(5):1941-1956. doi:10.1007/s10508-024-02850-4
24. Levine SB, Abbruzzese E, Mason JW. Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults. J Sex Marital Ther. 2022;48(7):706-727. doi:10.1080/009 2623X.2022.2046221
25. Drescher J. Informed Consent or Scare Tactics? A Response to Levine et al.'s "Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults". J Sex Marital Ther. 2023;49(1):99-107. doi:10.1080/0092623X.2 022.2080780
26. Cavanaugh T, Hopwood R, Lambert C. Informed Consent in the Medical Care of Transgender and Gender-Nonconforming Patients. AMA J Ethics. 2016;18(11):1147-1155. Published 2016 Nov 1. doi:10.1001/journalofethics.2016.18.11.sect1-1611
27. Parkinson P. Adolescent Gender Dysphoria and the Informed Consent Model of Care. J Law Med. 2021;28(3):734-744.
28. Baxendale S. The impact of suppressing puberty on neuropsychological function: A review. Acta Paediatr. 2024;113(6):1156-1167. doi:10.111 1/apa.17150
29. Nunes-Moreno M, Furniss A, Cortez S, et al. Mental Health Diagnoses and Suicidality Among Transgender Youth in Hospital Settings. LGBT Health. 2025;12(1):20-28. doi:10.1089/lgbt.2023.0394
30. Matouk K, Wald M. Gender-affirming care saves lives. 2022. Available:
https://www.columbiapsychiatry.org/news/gender-affirming-care-saves-lives [Accessed 17 Oct 2023].
31. Ruuska SM, Tuisku K, Holttinen T, Kaltiala R. All-cause and suicide mortalities among adolescents and young adults who contacted specialised gender identity services in Finland in 1996-2019: a register study. BMJ Ment Health. 2024;27(1):e300 940. Published 2024 Feb 17. doi:10.1136/bmjment-2023-300940
32. de Blok CJ, Wiepjes CM, van Velzen DM, et al. Mortality trends over five decades in adult transgender people receiving hormone treatment: a report from the Amsterdam cohort of gender dysphoria. Lancet Diabetes Endocrinol. 2021;9(10): 663-670. doi:10.1016/S2213-8587(21)00185-6
33. Wiepjes CM, den Heijer M, Bremmer MA, et al. Trends in suicide death risk in transgender people: results from the Amsterdam Cohort of Gender Dysphoria study (1972-2017). Acta Psychiatr Scand. 2020;141(6):486-491. doi:10.1111/acps.13164
34. Dhejne C, Lichtenstein P, Boman M, Johansson AL, Långström N, Landén M. Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PLoS One. 2011;6 (2):e16885. Published 2011 Feb 22. doi:10.1371/jo urnal.pone.0016885
35. Edwards-Leeper, L. et al. (2017). Psychological Profile of the First Sample of Transgender Youth Presenting for Medical Intervention in a U.S. Pediatric Gender Center. Psychology of Sexual Orientation and Gender Diversity 2017: 4(3) 374.
36. Chen D, Berona J, Chan YM, et al. Psychosocial Functioning in Transgender Youth after 2 Years of Hormones [published correction appears in N Engl J Med. 2023 Oct 19;389(16):1540. doi: 10.1056/NE JMx230007.]. N Engl J Med. 2023;388(3):240-250. doi:10.1056/NEJMoa2206297
37. Liszewski W, Peebles JK, Yeung H, Arron S. Persons of Nonbinary Gender - Awareness, Visibility, and Health Disparities. N Engl J Med. 2018;379 (25):2391-2393. doi:10.1056/NEJMp1812005
38. D'Angelo R. Supporting autonomy in young people with gender dysphoria: psychotherapy is not conversion therapy. J Med Ethics. 2024;51(1): 3-9. Published 2024 Dec 23. doi:10.1136/jme-2023-109282
39. Turban JL. Potentially Reversible Social Deficits Among Transgender Youth. J Autism Dev Disord. 2018;48(12):4007-4009. doi:10.1007/s10803-018-3603-0
40. Rea HM, Øien RA, Webb SJ, Bansal S, Strang JF, Nordahl-Hansen A. Gender Diversity, Gender Dysphoria/Incongruence, and the Intersection with Autism Spectrum Disorders: An Updated Scoping Review. J Autism Dev Disord. Published online December 4, 2024. doi:10.1007/s10803-024-06650-6
41. Taylor J, Hall R, Heathcote C, Hewitt CE, Langton T, Fraser L. Clinical guidelines for children and adolescents experiencing gender dysphoria or incongruence: a systematic review of recommendations (part 2). Arch Dis Child. 2024;109(Suppl 2):s73-s82. Published 2024 Oct 30. doi:10.1136/archdischild-2023-326500
42. Damiano, M. (2024, December 20). A leader in transgender health explains her concerns about the field. Boston Globe. https://archive.is/HrnIK
43. Sinai J, Sim P. Psychodynamic psychotherapy for gender dysphoria is not conversion therapy. J Can Acad Child Adolesc Psychiatry. 2024;33(2):145-153.
44. Hughes M. The WPATH Files: Pseudoscientific surgical and hormonal experimental treatments of children, adolescents and vulnerable adults. Environmental Progress, March 4, 2024.
45. Health and Human Services. (May 1, 2025). Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices https://opa.hhs.gov/sites/default/files/2025-05/gender-dysphoria-report.pdf
46. Rafferty J; COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH; COMMITTEE ON ADOLESCENCE; SECTION ON LESBIAN, GAY, BISEXUAL, AND TRANSGENDER HEALTH AND WELLNESS. Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents [published correction appears in Pediatrics. 2023 Oct 1;152 (4):e2023063756. doi: 10.1542/peds.2023-063756]. Pediatrics. 2018;142(4):e20182162. doi:10.1542/p eds.2018-2162
47. Cantor JM. Transgender and Gender Diverse Children and Adolescents: Fact-Checking of AAP Policy. J Sex Marital Ther. 2020;46(4):307-313. doi:10.1080/0092623X.2019.1698481
48. Zucker KJ. Debate: Different strokes for different folks. Child Adolesc Ment Health. 2020;25(1):36-37. doi:10.1111/camh.12330
49. McDeavitt K, Cohn J, Kulatunga-Moruzi C. Pediatric Gender Affirming Care is Not Evidence-based. Curr Sex Health Rep. 2025; 17, 12-17. https://doi.org/10.1007/s11930-025-00404-w
50. McDeavitt K, Cohn J, Levine SB. Critiques of the Cass Review: Fact-Checking the Peer-Reviewed and Grey Literature. J Sex Marital Ther. 2025;51 (2):175-199. doi:10.1080/0092623X.2025.2455133
51. United States v. Skrmetti, 605 U.S.___,2025 WL1698785 (June 18, 2025)
52. de Vries AL, McGuire JK, Steensma TD, Wagenaar EC, Doreleijers TA, Cohen-Kettenis PT. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014;134(4):696-704. doi:10.1542/peds.2013-2958
53. Irwig MS. Detransition Among Transgender and Gender-Diverse People-An Increasing and Increasingly Complex Phenomenon. J Clin Endocrinol Metab. 2022;107(10):e4261-e4262. doi:10.1210/cl inem/dgac356
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