Singapore joins the cautious club
New treatment guidelines in the Southeast Asian republic recommend no gender hormones or surgery for under-18s
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Singapore has issued its first set of treatment guidelines for youth gender dysphoria, advising doctors against any hormonal or surgical interventions with patients under 18.
The guidelines note the lack of high-quality evidence in the field and the concern that puberty blockers may lock in gender distress, making a transgender identity “inevitable” and preventing the re-embrace of birth sex.
“Children and adolescents below 18 years old who are diagnosed with [gender dysphoria] should not be offered hormonal and surgical treatment,” says a Ministry of Health Circular sent on May 5 to doctors and hospitals in the Southeast Asian republic of Singapore.
“Treatment for [gender dysphoria] should be sequential, starting from psychological, and moving on to hormonal and surgical treatment only for cases that are medically indicated.”
The circular, signed by Professor Kenneth Mak, Director-General of Health at the Ministry, highlights the risks associated with irreversible medical interventions given to young people “who are still developing their sense of identity”.
The circular comes with guidelines for (prepubertal) children and adolescents (from onset of puberty up to age 21) dated as finalised in July 2025.1
Citing the risk of long-term side effects and irreversible changes to the body, the adolescent guidelines recommend no cross-sex hormones before 21, the age of majority in Singapore.
However, adolescents aged 18-21 may be offered hormones “in exceptional circumstances where there is clear evidence of benefit or harm reduction (which may include medical/mental health grounds) and agreement from [a Treatment Review Panel]”, which must have one medical specialist member appointed from outside the treating team for objectivity.
It is unclear how this test of benefit and harm can be applied because, as the guidelines themselves state, “Research on adolescents with [gender dysphoria] is lacking.”
“The lack of robust research in this area leads to the uncertainty in offering advice and treatments to patients and their families.
“Many studies [in this field] have short follow-up periods. Longer-term outcome studies suffer from loss to follow-up, especially in the group where no medical treatment was offered. The outcomes of this group, often excluded from medical treatment because of greater mental health needs, are not known.”
Clinicians in Singapore are advised to make sure that any adolescents prescribed cross-sex hormones have “realistic ideas of treatment outcomes” and are “not acting under undue influence of other persons or information, whether interacting in-person or online”.2
Mix & match
The guidelines, drafted by clinician workgroups and running to 55 pages in total, use some “gender-affirming” language but also cite studies critical of that treatment approach and advocating greater caution.
The children’s guidelines say there is “no conclusive evidence” on whether social transition—where a child takes up new pronouns and an opposite-sex role, sometimes before puberty—is advisable.
“Social transitioning is associated with persistence of dysphoria from childhood to adolescence. It is not clear if it is a contributory factor to the persistence or merely an indicator of intense [gender dysphoria], which tends to persist,” the guidelines say.
The guidelines oppose any use of puberty blockers “due to the current lack of evidence surrounding safety or clinical effectiveness”, highlighting the precedent in the UK, where the National Health Service announced an end to routine puberty suppression for gender distress in 2024.
The Singaporean guidelines point out that the evidence favouring puberty blockers for gender dysphoria “is largely based on observational studies and [is] of low quality”.
Also referenced in the new guidelines is the historical finding—from before the era of early social transition and puberty blockers—that 80-95 per cent of prepubertal children outgrew their gender distress as they matured.
Singapore’s rationale for withholding puberty blocker treatment is that it “allows for the developmental trajectory of gender identity to unfold without pursuing or encouraging a specific outcome and the avoidance of potential irreversible impacts”.
“Adolescence is a developmental stage involving major changes in many aspects—biological, emotional and social—of a young person’s life. Professionals working with adolescents presenting with [gender dysphoria] should be familiar with these aspects and consider the impact of the developmental stage on the young person,” the adolescent guidelines say.
The guidelines stress the risks and potentially lifelong complications that come with cross-sex hormones, the high rates of co-morbid mental health issues in young people presenting with gender dysphoria, and the need for thorough assessment, differential diagnosis, and informed consent before any medical intervention.
“The prevalence of co-morbidity is high, particularly mood and anxiety disorders. Co-morbid diagnosis may occur independent of [gender dysphoria], may interact with the [dysphoric] symptoms and may affect its treatment,” the guidelines say.
The document lists potential co-morbidities such as autism, depression, anxiety, post-traumatic stress disorder, eating disorders, body dysmorphia, and borderline personality disorder. The guidelines say a careful assessment may take 12-18 months.
“[T]here may be a need to suspend gender-affirming medical interventions if a new diagnosis is made which significantly impacts the diagnostic and treatment process, for example, the development of psychosis with delusions can affect decision-making capacity of the individual,” the guidelines say.
Adolescents already prescribed cross-sex hormones will continue to get these drugs, subject to regular review by a Treatment Review Panel, according to the new guidelines.
In its May 5 circular, Singapore’s Ministry of Health says it “does not track medical interventions and hormone therapies specific to [gender dysphoria]” but, based on gender surgery notifications and clinical anecdote, the Ministry estimates the number of new gender patients in public healthcare as “low”.
In January 2025, the issue of puberty blockers was put on the parliamentary agenda with a question from MP and physician Dr Lim Wee Kiak, who asked about the ethics, risks and safeguards of puberty suppression for gender dysphoria.
Health Minister Ong Ye Kung replied—
“There is insufficient evidence to indicate that puberty blockers are safe for children or [that] there is significant clinical benefit to them, especially when most children do not remain gender dysphoric later in life. [The Ministry of Health] therefore does not recommend the use of puberty blockers for minors with gender dysphoria.”
Singapore’s new guidelines generally advise caution and restraint by practitioners.
“As there may be long-term, wide-ranging medical, psychological and social implications when hormonal, or hormonal and surgical, intervention is undertaken, healthcare professionals should err on the side of informed consent and harm minimisation,” the May 5 ministerial circular says.
The reference list for the adolescent guidelines includes the long-term Swedish study Dhejne et al, which drew on comprehensive health registry data, and concluded that the suicide rate for patients after medical transition was 19 times the rate for the general population.
“Longer-term outcome data [in the Dhejne study] suggests that mental health problems persist in this population and should continue to be monitored for, after medical or surgical transition,” the guidelines say.
Also cited is evidence published by the prominent psychiatrist Professor Riittakerttu Kaltiala and her Finnish colleagues that, as the Singaporean guidelines put it, “adolescent patients with pre-existing mental health and psychosocial dysfunction continue to have these problems one year after starting [cross-sex hormones]”.
“A high priority should be placed on avoidance of risks of long-term hormonal treatment because of the risks of side effects and irreversible consequences associated with medical therapy,” the guidelines say.
Among the risks specific to cross-sex hormones, the guidelines list (for males on oestrogen drugs) thromboembolic disease, breast cancer, coronary artery disease, cerebrovascular disease, among other conditions.
For females, the stated risks of testosterone drugs include dangerous thickening of the blood, severe liver dysfunction, coronary artery disease, cerebrovascular disease, hypertension, and breast or uterine cancer.
As for gender surgery, the Singaporean guidelines advise against this intervention before the age of 21, with possible exceptions for patients aged 18-21 “where there is clear evidence of benefit or harm reduction”. Again, it is not clear how this test would be applied.
“Surgeons should bear in mind that young people [sterilised by genital gender surgery] may not desire or plan for children during adolescence but may change their minds as they grow into adulthood, regardless of their identified gender, sexuality or final physical appearance,” the guidelines say.
“There are potential severe and life-long risks associated with [gender surgery]. These include complications of the urinary and gastrointestinal systems, and external/cosmetic disfigurement.”
The guidelines prioritise psychosocial interventions for young people with gender distress but acknowledge that here too the evidence is poor.
“While there is no definite psychotherapy approach that has been established as evidence-based intervention for [gender dysphoria] at this point in time, any form of psychotherapy provided to adolescents with [gender dysphoria] should be welcoming and supportive,” the guidelines say.
Thanks to Billboard Chris for sourcing the documents. GCN put questions to Singapore’s Ministry of Health but there was no reply at the time of writing.
The controversial online clinic GenderGP, co-founded by UK physician Dr Helen Webberley, is registered as a legal entity in Singapore. Its website, however, says it “does not provide any services in Singapore”. In 2024, it was reported that Singaporean authorities had blocked GenderGP from local users.