European policies in relation to minors with gender dysphoria

A comparative analysis

In a recent article published in Medscape, one of the main online reference websites for doctors and health professionals, the policies recently adopted in different European countries regarding the approach to gender dysphoria in minors, which mostly are being redirected towards an approach of more psychological support, warning of the dangers of using hormone blockers at an early age.

Puberty blockers, approved for the treatment of precocious puberty, are being used in minors with gender dysphoria to stop or delay the adolescent maturation process to reduce the sexual differentiation typical of this stage with a view to a later surgical transition. of genre. The side effects associated with these treatments have been previously analyzed in our Observatory, and are very worrying and, in many cases, irreversible.

Although some activists and transgender associations advocate their use, medical evidence shows that they are not safe and seriously questions their effectiveness.

In the United Kingdom, Dr. Hilary Cass, former president of the Royal College of Paediatricians and Child Health, published the Cass Review report in April 2024, driven by the significant increase in demand for gender identity treatments among children and adolescents. . Dr. Cass found “remarkably weak evidence” to support gender treatments for children.

In March, England’s National Health Service (NHS) announced it would no longer prescribe puberty blockers to children at gender identity clinics due to a lack of evidence supporting their safety or effectiveness.

On April 18, Scotland’s only gender clinic reported that it had also stopped prescribing puberty blockers to under-18s, and that new underage patients would no longer receive other hormonal treatments.

It should be remembered that in March 2023, the British Government vetoed the Scottish gender law that facilitated gender transition at 16 years of age. This law lowered the minimum age for sex change from 18 to 16 years and eliminated the need to present a medical report along with evidence confirming having lived at least 2 years with that intention.

In Germany, Alexander Korte, a child psychiatrist at the Ludwig Maximilian University of Munich, believes that “this therapy is irresponsible due to the unclear data situation. The administration of opposite-sex hormones after puberty blockers, as is known occurs in more than 95% of children treated with gonadotropin-releasing hormone (GnRH) analogues, leads to permanent infertility, in addition to a permanent impairment of the ability to experience sexuality.

In Finland, Dr. Riittakerttu Kaltiala says puberty blockers can only be considered for use after a multidisciplinary evaluation at one of the nationally centralized gender identity units for minors.

In the Netherlands, the guidelines have not yet been revised. However, in February 2024, Parliament ordered that research be carried out into the physical and mental health outcomes of children prescribed puberty blockers.

In Norway, the Healthcare Research Board (Ukom) recommended in 2023 that the Ministry of Health and Care commission the Directorate of Health to revise the national guideline on gender in congruence so that it is based on a systematic summary of available evidence. The Ukom report recommended that puberty blockers and hormonal and surgical gender reassignment treatment for children and young people be defined as experimental treatments.

In France, the National Academy of Medicine recommended in 2022 “greater reserve” regarding the use of puberty blockers in children and adolescents. However, if they have parental authorization, they can continue to be prescribed.

In Sweden, the National Board of Health and Welfare stated in 2022 that the risks of puberty blockers and gender reassignment hormone treatments for people under 18 years of age outweighed their potential benefits. Despite this, he added that hormone treatment should continue to be administered, but within a research framework to better understand its impact on gender dysphoria, mental health and quality of life in this age group, being able to continue with treatment in exceptional cases.

In Spain, the Law for the Equality of Trans People and the Guarantee of LGBTI Rights contemplates medication with puberty blockers and legal sex change from the age of 12, ignoring experts’ warnings about the serious risks of this practice.

Suicide risk

A recent article analyzing the prevalence of suicide and self-harm risk in people who have undergone sex reassignment surgery, using TriNeX patient data with a sample of 15.6 million people in the United States, covers 20 years (2003-2023).

The sample consists of four groups of people between 18 and 60 years old: group A is made up of patients who have undergone a sex reassignment operation, group B are patients who have not undergone surgery to change their sex, Group C are people who have had a tubal ligation or a vasectomy and group D are people who have had pharyngitis.

After analyzing the suicide risks of patients in the four groups, the study concludes that people who had undergone sex reassignment surgery have a risk 12 times higher than people who had not had surgery.

As we have recently published in our Observatory, a new work published in the journal BMJ Mental Health questions the effectiveness of gender transition interventions as a method to prevent suicidality in people affected by gender dysphoria.

But this evidence has been revealed in previous studies for years. Thus, the work of Dhejne et al., published in 2011, already concluded that there are substantially higher rates of general mortality, death from cardiovascular disease and suicide, suicide attempts, and psychiatric hospitalizations in transsexuals with sex reassignment compared to a healthy control population. It highlights that post-surgical transsexuals are a risk group that needs long-term psychiatric and somatic follow-up. Although, in the short term, surgery and hormone therapy appear to alleviate gender dysphoria, they are not sufficient to remedy the high rates of morbidity and mortality found among transsexual people.

Bioethical assessment

Addressing the problem of gender dysphoria, like other disorders that need clinical attention and treatment, requires, as in all good medical practice, rigorous recourse to the available scientific evidence, which shows the risk/benefit relationship of the different therapeutic options. Its scrupulous analysis will allow treatments to be started or withdrawn depending on their evolution, results, side effects or effectiveness.

Thus, it is not uncommon for therapeutic standards of previously approved treatments to be rectified that end up being suspended or modified due to the lack of evidence of a clearly positive benefit/risk balance.

In the case of treatments with puberty blockers for children and adolescents with gender dysphoria, it must be clarified that there are no authorizations approved by the competent bodies for this use and their use is called “off label” or “outside authorized prescription.” ”.

One of the reasons that has been given for applying unauthorized treatments in this case is its alleged ability to reduce the risk of suicide or suicidal ideation in those affected, which is precisely what is now strongly questioned.

But in addition to the fact that the evidence on its effectiveness for this purpose is increasingly weaker and called into question, data is accumulating on the undesirable effects associated with these treatments, which in many cases are irreversible, as has already been stated.

The movements that occur by professionals, scientific societies or regulatory bodies, modifying the indication and application criteria of these treatments, respond to the need to address the available scientific evidence, as required by good medical practice.

But there are serious questions that have not been properly answered and that we raise in conclusion: why were these treatments initiated and universalized if solid evidence was not available to support them? Why have the data that strongly question its efficacy and safety and that accumulate as there are more possibilities of monitoring those affected have been ignored or not adequately evaluated? And, finally, why have countries like Spain not undertaken, unlike other countries, absolutely any modification to what is established in the law that regulates these interventions, known as the Trans Law, which appears to be reckless, interventionist, inconsistent and evil? And it is because it does not take into account scientific evidence or follow criteria of good medical practice.

The answers to these questions will most likely not be found in the scientific field, but in the ideological one. And we regret it because the consequences of malpractice are detrimental to the health of those affected and their right to receive quality care, accompanied by sufficient, verified and updated information.

Julio Tudela – Ester Bosch – Bioethics Observatory – Life Sciences Institute – Catholic University of Valencia