2023-2-07 Affidavit draft

Affidavit of Jamie Reed

Jamie Reed, being sworn, states:

1. I am an adult, I am under no mental incapacity or disability, and I know that the facts set

forth in this affidavit are true because I have personal knowledge of them.

2. I hold a Bachelors of Arts in Cultural Anthropology from the University of Missouri St.

Louis and a Master’s of Science in Clinical Research Management from Washington

University.

3. I have been working at Washington University for seven years. Initially at Washington

University, I worked with HIV-positive patients, caring for many transgender individuals.

4. From 2018 until November 2022, I worked as a case manager at the Washington

University Pediatric Transgender Center (“the Center”) at St. Louis Children’s Hospital.

My duties included meeting with patients two to three days a week and completing the

screening triage intake of patients who were referred to the Center.

5. I was offered and accepted the job as case manager for the Center because I had

experience and expertise in working with transgender individuals and pediatric

populations.

6. I took the job because I support trans rights and firmly believed I would be able to

provide good care for children at the Center who are appropriate candidates to be

receiving medical transition. Instead, I witnessed the Center cause permanent harm to

many of the patients.

7. During my time at the Center, I personally witnessed Center healthcare providers lie to

the public and to parents of patients about the treatment, or lack of treatment, and the

effects of treatment provided to children at the Center. I witnessed staff at the Center

provide puberty blockers and cross-sex hormones to children without complete informed

parental consent and without an appropriate or accurate assessment of the needs of the

child. I witnessed children experience shocking injuries from the medication the Center

prescribed. And I saw the Center make no attempt or effort to track adverse outcomes of

patients after they left the Center.

8. I raised concerns internally for years. But the doctors at the Center told me to stop raising

these concerns. Last fall, the Center and the University Administration told me to “get

with the program or get out.” Because the Center was unwilling to make any changes in

response to my concerns, I left the Center in November 2022 and accepted employment

elsewhere within Washington University.

The Center Misleads the Public and Parents About What Care it Provides

9. The Center tells the public and parents that it provides multidisciplinary care. The Center

says that you can come to the clinic and get transition hormones, if that is needed, but

you can also get psychological and psychiatric care.

10. That is not true. The Center says that it has four practice areas: Endocrinology,

Adolescent Medicine, Psychiatry, and Psychology. But the Center placed such strict

limits on Psychiatry and Psychology that I was almost never allowed to schedule patients

for those practices. Those practices were advertised as available, but most of the time

they were not in fact available. Even when psychology was available, it was only to write

a letter of support for the medical transition treatments and never for ongoing therapy.

And psychiatry was allowed, but only on an extremely limited basis.

11. Instead, I was required to schedule children for Endocrinology or Adolescent Medicine.

Rather than provide psychiatric or psychological therapy, these practices (Endocrinology

and Adolescent Medicine) would medically transition patients’ gender. Endocrinology

would prescribe puberty blockers and cross-sex hormones. Adolescent Medicine, which

was for children after puberty, prescribed cross-sex hormones. Children were sent to one

practice or the other based on their age and stage of puberty or prepuberty. There was no

continuing or ongoing mental health evaluation or treatment required or provided by the

Center for patients.

12. The Center also claims that it is a multidisciplinary team approach. The benefit of that

approach is supposed to be that patients and their parents can feel more confident that all

aspects of their care options have been considered and that their treatment plan has the

input of all of the team. This Center did have members who would advocate for different

options for the patients with concerning gender histories, concerning comorbidities, and

attempt to raise the serious concerns regarding patient care. Patients and their parents,

however, were never informed that the team did not have consensus on the treatment. The

staff members on the team that were not universally in support of immediate cross sex

hormones were not supported and were told to stop questioning the prevailing narrative

of immediate cross sex hormones for all by the prescribing physicians. The

administration at the university did not actively support the multidisciplinary model of

care and did not provide any oversight, and instead the administration told those raising

concerns and questions to stop raising them. The public has been led to believe that a

‘team’ has considered their child’s care and that the ‘team’ had ruled it best for the cross

sex hormones to be initiated, but the public was not told the truth.

13. Medical transition practice for children and adolescents is based on a study from the

Netherlands. That study, the “Dutch study,” excluded participants who presented

underlying mental health issues.

14. But nearly all children who came to the Center here presented with very serious mental

health problems. Despite claiming to be a place where children could receive

multidisciplinary care, the Center would not treat these mental health issues. Instead,

children were automatically given puberty blockers or cross-sex hormones even though

the Dutch study excluded persons experiencing mental health issues.

15. One patient came to the Center identifying as a “communist, attack helicopter, human,

female, maybe non binary.” The child was in very poor mental health and early on

reported that they had no idea their gender identity. Rather than treat the child for their

serious mental health problems, the Center put the child on cross-sex hormones and

ignored the child’s obvious mental health problems. The child subsequently reported that

their mental health actually was worsening once they started the cross-sex hormones.

16. Most children who come into the Center were assigned female at birth. Nearly all of them

have serious comorbidities including, autism, ADHD, depression, anxiety, PTSD, trauma

histories, OCD, and serious eating disorders. Rather than treat these conditions, the

doctors prescribe puberty blockers or cross-sex hormones. Some examples include:

a. Patient was in a residential sex offender treatment facility in state custody. Patient had

previously sexually abused animals and had stated when they were released that they

would do so again. There were questions about consistency of gender history. The

Center did not treat this underlying condition, but instead started the patient on

hormones.

b. Patient who has severe Obsessive Compulsive Disorder and had threatened to

self-harm their genitals. The Patient did not have a trans or other incongruent gender

identity. The patient was placed on hormones not even to treat any gender dysphoria

but to chemically reduce libido and sexual arousal.

c. Patient had history of sexual abuse and notified the psychologist of this. It was even

documented in the letter of support that the patient had concerns about the changes

that testosterone would cause to their genitals. Instead of treating the underlying

trauma the patient was started on testosterone.

d. Patient had serious mental health concerns and was prescribed mental health

medications directly before being prescribed hormones, yet didn’t take the mental

health medications. Nevertheless, the patient was placed on hormones.

e. Patient had significant autism with unrealistic expectations, struggled to answer

questions, and wanted questions to be provided ahead of time. Yet the patient was

started on feminizing hormones.

f. Patient had a mental health history that included being violent. In addition, the parent

was forcing the patient to cross dress. The patient was put on feminizing hormones.

17. These serious comorbidities were not treated by the Center, and doctors would prescribe

puberty blockers or cross-sex hormones while patients were struggling with these

comorbidities.

18. The psychiatry services were limited and could only serve patients who were ‘not too

severe,’ which meant that many patients were being sent to the already overburdened

emergency rooms for suicidal ideations, for self-harm, and for inpatient eating disorder

treatment.

19. Many patients had depression and anxiety symptoms before starting cross sex hormones

but it was only after starting these medications that they became more severe and

required starting mental health medications. Many patients were also suspected of having

autism and were not even required to be formally assessed for this condition before

starting cross sex hormones.

20. Toward the end of my time at the Center, it became clear that many children coming to

the Center had gender identities that were likely the result of social contagion. When I

first started in 2018, the Center would receive between 5 and 10 calls a month. By the

time I left, that number was more than 40 calls a month.

21. Social media is at least partly responsible for this large increase in children seeking

gender transition treatment from the Center. Many children themselves would say that

they learned of their gender identities from TikTok. Children would arrive at the Center

identifying not only as transgender, but also as having tic disorders (Tourette Syndrome)

or multiple personality disorders (dissociative identity disorder). Doctors at the Center

would ignore and dismiss as social contagion the claims about the tics and multiple

personalities; but then those doctors would uncritically accept the children’s statements

about gender identity and place these children on puberty blockers and cross-sex

hormones.

22. In one case, a child came into the Center identifying as “blind,” even though the child

could in fact see (after vision tests were performed). The child also identified as

transgender. The Center dismissed the child’s assertion about blindness as a somatization

disorder but uncritically accepted the child’s statement about gender and prescribed that

child with drugs for medical transition without confirming the length or persistence of the

condition. No concurrent mental health care was provided.

23. The Center tells the public and parents of patients that the point of puberty blockers is to

give children time to figure out their gender identity. But the Center does not use puberty

blockers for this purpose. Instead, the Center uses puberty blockers just until children are

old enough to be put on cross-sex hormones. Doctors at the Center always prescribe

cross-sex hormones for children who have been taking puberty blockers.

24. The Center also tells parents, children, and the public that puberty blockers are fully

reversible. They are not. In children going through normal puberty, puberty blockers do

lasting damage. They cause children to go through menopause early, they reduce bone

density, and they worsen mental health.

25. Doctors at the Center also have publicly claimed that they do not do any gender transition

surgeries on minors. For example, last year Dr. Lewis and Dr. Garwood told the Missouri

legislature, “at no point are surgeries on the table for anyone under 18” and also,

“surgeries are not an option for anyone under 18 years of age.” This was a lie. The Center

regularly refers minors for gender transition surgery. The Center routinely gives out the

names and contact information of surgeons to those under the age of 18. At least one

gender transition surgery was performed by Dr. Allison Snyder-Warwick at St. Louis

Children’s Hospital in the last few years.

26. During medical visits with patients, I have personally heard providers report that they

examined results of gender transition surgeries on minors. This includes examining the

scar tissue and healing of sutures of breast surgeries.

27. At one point, Dr Chris Lewis and Dr Sarah Garwood reported that the Endocrine division

leadership didn’t want us referring minors for surgery. Yet, the Center continued

referring minors for surgery. We claimed that the referrals were only “for educational

purposes” for when children turned 18. But these referrals were in fact referrals. And

patients we referred did in fact obtain transition surgeries as minors.

The Center Does Not Assess Children or Obtain Consent Before Placing them on

Puberty Blockers and Hormones

28. The Center has four criteria that must be met before a child is placed on puberty blockers

or cross-sex hormones. Although these criteria are supposed to enable the doctors to

make case-by-case decisions, in practice everybody who meets these minimum criteria

are prescribed cross-sex hormones or puberty blockers.

(1) Age

29. First, the child must be at a certain age or stage of puberty. Puberty stages are measured

according to the Tanner Stage system.

30. The World Professional Association for Transgender Health (“WPATH”) is an

organization that drafts what it believes to be the best medical standard of care. WPATH

is controversial. It is considered an activist organization, and its standards of care (or

“guidelines”) are much more lenient than the standards of care created by other

organizations.

31. During the time, I was at the clinic, the WPATH Standard of Care Version 7 stated that

children be at least 16 years old to start using cross-sex hormones. The Center deviated

even from this most lenient standard and routinely prescribed cross-sex hormones to

children as young as 13.

(2) Therapist Letter

32. The second criteria for a person to receive puberty blockers or cross-sex hormones is that

the child have a letter of referral from a therapist. This requirement is supposed to ensure

that two independent professional clinicians agree that medical transition is appropriate

before a child is given medication that causes irreversible change. But nothing about this

process at the Center involved independent judgment.

33. The Center steered children toward therapists that the Center knew would refer these

children back to the Center with a letter supporting medical transition. The Center had a

list of therapists we would send children to, and a therapist could be on that list only if

the Center “knew they would say yes” to medical transition. The Center had two in-house

psychologists. They were Dr. Alex Maixner and Dr. Sarah Girresch-Ward as well as

several outside therapists. Nobody on our list was required to be licensed in psychology

or psychiatry.

34. If we did not receive a letter from an outside therapist that would let us prescribe puberty

blockers or cross-sex hormones, we would then just send the patient to the in-house

therapists: Dr. Alex Maixner and Dr. Sarah Girresch-Ward.

35. We also instructed the therapists what to say in their letters to us. I was instructed to draft

and send language to the therapists for them to use in letters they then sent to us, and

most therapists on the list had a template letter drafted by the Center that they could fill

out to return to the Center.

36. The WPATH guidelines require a full psychological assessment of the child before

recommending puberty blockers or cross-sex hormones. A full assessment typically

requires 10 to 12 hours of time with the child. Therapists on the Center’s list would send

us letters after just 1-2 hours with a patient.

(3) Consent

37. The third criteria was parental consent. The Center routinely issued puberty blockers or

cross-sex hormones without parental consent.

38. Doctors at the Center routinely pressured parents into “consenting” by pushing those

parents, threatening them, and bullying them.

39. A common tactic was for doctors to tell the parent of a child assigned female at birth,

“You can either have a living son or a dead daughter.” The clinicians would tell parents

of a child assigned male at birth, “You can either have a living daughter or dead son.”

The clinicians would say this to parents in front of their children. That introduced the idea

of suicide to the children. The suicide assertion was also based on false statistics. The

clinicians would also malign any parent that was not on board with medicalizing their

children. They would speak disparaging of those parents.

40. I was present during the visits with many parents when this happened.

41. Parents would come into the Center wanting to discuss research and ask questions. The

clinicians would dismiss the research that the parents had found and speak down to the

parents.

42. When parents suggested that they wanted only therapy treatment, not cross-sex hormones

or puberty blockers, doctors treated those parents as if the parents were abusive,

uneducated, and willing to harm their own children.

43. These assertions about abuse and suicide were used as tools to stop parents from asking

questions and to pressure parents into consenting.

44. The Center has a team culture of supporting the affirming parent and maligning the

non-affirming parent.

45. Parents routinely said they felt they were being pressured to consent. Often parents would

give “consent” but say they were only doing so because “you guys are going to do this

anyway.”

46. The Center was also intentionally blind about who had legal authority to consent. I

wanted the Center to ask parents before the first visits about and request copies of

custody agreements because custody agreements often spell out who among divorced

parents must consent to medical procedures. I was told not to ask for custody agreements

because “if we have the custody agreement, we have to follow it.”

47. At one point, a child’s father said no to cross-sex hormones. The child later arrived with

an adult male (step parent) who said the child could receive cross-sex hormones. The

Center did not check to see if this adult male was a legal parent or guardian who had any

legal right to consent to treatment.

48. Other centers who prescribe cross-sex hormones and puberty blockers require parents to

issue written consent. Several times, I asked the doctors to require written consent. They

repeatedly refused. The entire time I worked there the Center had no written informed

consent, and none that was provided to or signed by patients.

49. On several occasions, the doctors have continued prescribing medical transition even

when a parent stated that they were revoking consent.

50. Before placing children on cross-sex hormones or puberty blockers, the Center also did

not inform parents or children of the very serious side effects.

51. Doctors know that cross-sex hormones (immediately after puberty blockers) make

children permanently sterile. The doctors did not share this information with parents or

children.

52. For example, the Center nurse and I expressed concerns about a patient’s intellectual

function and ability to provide informed consent. The patient had a history of attending a

school district for special education needs, couldn’t identify where they lived, and

couldn’t explain what kind of legal documents (ID) they had. Our concerns were

dismissed by the provider, and hormones were given. Patient then stated in a follow up

appointment that they wanted to potentially have biological children and had not been

seen by the fertility department. When the nurse and I asked the Center provider if they

had covered the fertility questions, the Center provider became livid and adamantly

disagreed that treatment could “potentially render the patient sterile.”

53. Doctors knew that many of our former patients had stopped taking cross-sex hormones

and were detransitioning. Doctors did not share this information with parents or children.

(4) Clinical Visit

54. The fourth criteria for prescribing cross-sex hormones or puberty blockers is that the

child must have a one-hour consultation with Endocrinology or Adolescent Medicine.

55. This is little more than a box-checking exercise. One hour is not sufficient time to fully

assess these children. I witnessed doctors on several occasions’ mention that they did not

have time in the meeting to discuss everything they wanted to discuss. The Center

decided to give these children cross-sex hormones and puberty blockers anyway.

56. The WPATH standard of care in effect when I was at the Center required a full

assessment of a child’s situation. That typically cannot be done in less than 10 or 12

hours. The Center ignored this standard and gave children puberty blockers and cross-sex

hormones after just two 1-hour visits (one with a therapist and one with a doctor at the

Center).

Cross-Sex Hormones and Puberty Blockers Are Automatic

57. The Center tells the public and parents that it makes individualized decisions. That is not

true. Doctors at the Center believe that every child who meets four basic criteria—age or

puberty stage, therapist letter, parental consent, and a one-hour visit with a doctor—is a

good candidate for irreversible medical intervention. When a child meets these four

simple criteria, the doctors always decide to move forward with puberty blockers or

cross-sex hormones. There were no objective medical test or criteria or individualized

assessments.

58. The doctors do this even though many children coming to the Center are either

experiencing social contagion or have very serious mental health issues that should be

addressed first. The standard of care in studies says a center should resolve mental health

issues before sending children through medical transition. The Center is not following

that standard.

59. Children come into the clinic using pronouns of inanimate objects like “mushroom,”

“rock,” or “helicopter.” Children come into the clinic saying they want hormones because

they do not want to be gay. Children come in changing their identities on a day-to-day

basis. Children come in under clear pressure by a parent to identify in a way inconsistent

with the child’s actual identity. In all these cases, the doctors decide to issue puberty

blockers or cross-sex hormones.

60. In one case where a girl was placed on cross-sex hormones, I found out later that the girl

desired cross-sex hormones only because she wanted to avoid becoming pregnant. There

was no need for this girl to be prescribed cross-sex hormones. What she needed was basic

sex education and maybe contraception. An adequate assessment before prescribing

hormones would have revealed this fact. But because the doctors automatically prescribe

cross-sex hormones or puberty blockers for children meeting the bare minimum criteria,

this girl was unnecessarily placed on drugs that cause irreversible change to the body.

61. On another occasion, a patient had their breasts removed. Although the patient had turned

18, this surgery was performed at St. Louis Children’s Hospital. Three months later, the

patient contacted the surgeon and asked for their breasts to be “put back on.” Had a

requisite and adequate assessment been performed before the procedure, the doctors

could have prevented this patient from undergoing irreversible surgical change.

62. In July 2022, the FDA issued a “black box warning” for puberty blockers, the strictest

kind of warning the FDA can give a medication. It issued the warning following evidence

in patients of brain swelling and loss of vision. Despite this warning, doctors at the

Center continued their automatic practice of giving kids these drugs.

63. In more than four years working at the clinic, I witnessed only two examples of the

doctors deciding not to prescribe cross-sex hormones or puberty blockers for a child who

met the four basic criteria. Both cases involved patients with severe developmental

delays. And in one of those cases, the doctors in fact said that they would prescribe

cross-sex hormones or puberty blockers. The only reason the doctor did not prescribe

those medications was that the parents would not agree to monitor administration of the

medication.

64. In hundreds of other cases, Center doctors automatically issued puberty blockers or

cross-sex hormones without considering the child’s individual circumstances or mental

health.

65. In one case, a psychiatrist called the Center’s endocrinologist and explained that a child,

who had already tried to commit suicide by threatening to jump off a roof, should not be

given cross-sex hormones because the child was struggling with serious mental health

issues. I witnessed the endocrinologist yell at the psychiatrist on the phone and speak

down to this provider.

66. Because I was concerned that the doctors were giving cross-sex hormones and puberty

blockers to children who should not be on them, I created a “red flag” list of children

where other staff and I had concerns. The doctors told me I had to stop raising these

concerns. I was not allowed to maintain the red flag list after that.

67. During the time I was creating the red flag list, noting my concern that these children

were not good candidates for permanent, irreversible medication treatment, the doctors

would simply send these children to our in-house therapists. Those therapists would

inevitably provide letters to the doctors, and then the doctors would say there can’t be any

concern over these children because another therapist was fine with prescribing puberty

blockers or cross-sex hormones.

Children Are Experiencing Serious Harm, and the Center Will Not Do Any Follow Up

68. It is my professional opinion that cross-sex hormones and puberty blockers should only

be used where the benefits outweigh the harms. These drugs have imposed and are

imposing serious harms on the children who have been patients at the Center.

69. The doctors at the Center tell the public and tell parents of patients that puberty blockers

are fully reversible. They really are not. They do lasting damage to the body.

70. I have seen puberty blockers worsen the mental health outcomes of children. Children

who have not contemplated suicide before being put on puberty blockers have attempted

suicide after. Puberty blockers force children to go through premature menopause.

Puberty blockers decrease bone density.

71. Cross-sex hormones (after puberty blockers) in almost all cases will permanently sterilize

children. Children on cross-sex hormones also experience substantial gain in blood

pressure, cholesterol, and weight. All of these have significant negative health effects.

One patient started hormones and took one dose and then started having symptoms that

they believed was indicative of a blood clot.

72. Children who take testosterone as a cross-sex hormone experience severe atrophy of

vaginal tissue. One patient on cross-sex hormones called the Center after having sexual

intercourse. The patient experienced vaginal lacerations so severe that the patient bled

through a pad, through pants, and through a towel wrapped around their waist, and had to

have the vaginal lacerations surgically treated in St. Louis Children’s Hospital emergency

room.

73. Most patients who have taken cross-sex hormones have experienced near-constant

abdominal pain.

74. One doctor at the Center, Dr. Chris Lewis, is giving patients a drug called Bicalutamide.

The drug has a legitimate use for treating pancreatic cancer, but it has a side effect of

causing breasts to grow, and it can poison the liver. There are no clinical studies for using

this drug for gender transitions, and there are no established standards of care for using

this drug.

75. Because of these risks and the lack of scientific studies, other centers that do gender

transitions will not use Bicalutamide. The adult center affiliated with Washington

University will not use this medication for this reason. But the Center treating children

does.

76. I know of at least one patient at the Center who was advised by the renal department to

stop taking Bicalutamide because the child was experiencing liver damage. The child’s

parent reported this to the Center through the patient’s online self-reporting medical chart

(MyChart). The parent said they were not the type to sue, but “this could be a huge PR

problem for you.”

77. I have heard from patients given testosterone that their clitorises have grown so large that

they now constantly chafe against the child’s pants, causing them pain when they walk.

78. Despite telling the public and parents that the Center offers multidisciplinary, complete

care, the Center makes no attempt to provide care after prescribing cross-sex hormones or

puberty blockers. The Center does not provide mental health care or refer children for

mental health care even though nearly all children who come to the Center are

experiencing serious mental health issues. The Center does not require children to

continue with mental health care after they prescribe cross-sex hormones or puberty

blockers and even continues those medications when the patients directly report

worsening mental health after initiating those medications. Some additional examples to

those discussed above include:

a. Patient was on hormones and had decompensating mental health, outlandish name

changes, self-diagnosis of multiple personalities (DID). The patient was continued on

hormones.

b. Patient believed that they were being poisoned by the testosterone and stopped for a

period. They had significant serious mental health issues, but were put back on

testosterone.

c. Patient was brought to the Center at the age of 17 by a man who was not related to

them yet with whom the patient had been living. They were started on hormones as

soon as they turned 18. Patient’s mental health subsequently got worse and it was

disclosed in an Emergency Department visit that the man that had brought them to the

clinic had been sexually and physically abusing them. The medical transition

treatment was not stopped and the Center provider did not require trauma therapy,

mental health care or an assessment.

d. Patient was in residential facility, in foster care. We convinced the staff that it was ok

for patient to start testosterone. Patient ran away numerous times from facility and

was having unprotected intercourse while on testosterone (which causes birth

defects). The patient was continued on the testosterone.

e. Patient admits that they were started on testosterone when they were very young- age

11- and only because they were moving to a state (Florida) that the parent was

concerned wouldn’t prescribe later. Patient has desisted in male identity to a vague

non binary with their own self-diagnosis of autism. Patient has changed their name

numerous times and is clearly struggling with thoughts about desistence, even saying

they wanted breast development. The Center continued the testosterone.

f. Patient who was on hormones was being evaluated for OCD and having somatization

disorder with ‘seizure’ activity. Patient was kept on hormones.

g. Patient who was on hormones stopped taking their schizophrenia medications without

consulting a doctor. Patient was continued on hormones.

h. Patient changed to non-binary identity, then changed preferred name and stated that

their identity was shifting day to day. Patient was continued on hormones.

79. The Center also refuses to track complications and adverse events among its patients.

There is no standard protocol for tracking patients who have received treatment. And the

Center actively avoids trying to learn about these adverse events.

80. On my own initiative, I have tracked some patients on a case-by-case basis, but the

Center discouraged me from doing so. I wanted to track the number of our patients who

detransition. I wanted to track the number of our patients who have attempted suicide or

committed suicide. The Center would not make either of these tracking systems a

priority.

81. It is my belief that the Center does not track these outcomes because they do not want to

have to report them to new patients and because they do not want to discontinue

cross-sex hormone prescriptions. The Center never discontinues cross-sex hormones, no

matter the outcome.

82. In just a two-year period from 2020 to 2022, the Center initiated medical transition for

more than 600 children. About 74% of these children were assigned female at birth.

These procedures were paid for mostly by private insurance, but during this time, it is my

understanding that the Center also billed the cost for these procedures to state and federal

publicly funded insurance programs.

83. I have personally witnessed staff say they were uncomfortable with how the Center has

told them they have to code bills sent to publicly funded insurance programs. I have

witnessed staff directly ask the providers for clarification on billing questions and have

providers dismiss the concerns and work to have the patients have this care covered as

the priority.

84. I have personally witnessed staff report that they were aware that patients had been coded

incorrectly (coding for precocious puberty for puberty blockers when the child does not

in fact have that condition).

85. Based on my observation that the Center has prescribed puberty blockers or cross-sex

hormones hundreds of times where they should not have, the Center is billing private and

public insurance for unnecessary procedures.

86. Even when it is clear that the cross-sex hormones or puberty blockers are harming the

child, the Center continues that treatment and continues billing public and private

insurance.