Transgender person.
More and more European countries are taking a more cautious approach to gender-affirming care for minors. For example, in March of this year Norwegian Health Research Council announced it would review its current clinical recommendations regarding “gender-affirming care” for minors. The updated guidelines would limit the use of puberty blockers, sex hormones and menopause-related surgery to clinical trial settings. Norway joins other European countries, such as Finland, Sweden and the UK, in introducing limits on the provision of gender-affirming care to minors.
In the US, a partisan divide is emerging between states that allow and guarantee access to gender-affirmative care for youth and states that prohibit or severely restrict gender-affirmative care for minors. There doesn’t seem to be much middle ground.
So far this year 12 states have banned or severely restricted it gender affirming care for minors. More Republican-led states are expected to follow soon.
At the same time, five Democratic-led states passed legislation designed to legally protect transgender healthcare coverage and access for minors.
As seen by proponents and advocates, the idea behind gender affirming care is to provide medical treatment so that a person can “live like the gender they are.”
There is some evidence that gender-affirming care pays off in the short term improvement in health outcomes, in terms of less depression, anxiety and suicidality.
Angela Goepferd, program director for gender health at Children’s Minnesota says access to health care for trans minors is “life-saving.” Goepferd suggests that children with access to gender-affirming care “have less anxiety, are less depressed, less likely to think about suicide, and less likely to act on those suicidal thoughts.”
In the US, talk of introducing crash barriers is sometimes met with being branded a “transphobe” or a “scientific denier.”
But caution regarding gender-affirming care for minors may be warranted, as evidenced by European experience. A range of European based systematic reviews of evidence low certainty of benefit has been demonstrated for the benefits and risks of puberty blockers and sex steroids. Specifically, longitudinal data collected and analyzed by public health authorities in Finland, Sweden, the Netherlands and England have concluded that the risk-benefit ratio of young people’s gender transition ranges from unknown to unfavorable.
As a result, there has been a gradual shift across Europe from care that prioritizes access to pharmaceutical and surgical interventions to a less medicalized and more conservative approach that addresses potential psychiatric comorbidities and explores the developmental etiology of transidentity.
This in turn led to the imposition of limits in Europe on access to hormones. Currently, minors in most European countries have access to puberty blockers and sex hormones, but only if they meet strict conditions. And that increasingly happens in the context of a tightly controlled research environment.
Many European countries do not allow the use of sex hormones until the age of 16, and only then after completing a number of psychotherapy sessions. In addition, the vast majority of European countries prohibit surgery up to the age of 16.
From puberty blockers to sex hormones to surgery, the rules across Europe tend to be stricter than many jurisdictions in the US or tightened. For example, the Swedish National Board of Health and Welfare states that children should not be given puberty blockers outside of clinical trials, and that they should be at least 12 years old.
In England, one of the reasons for this to block Tavistock’s Gender and Identity Development Service in 2022, doctors reported concerns that some patients had been referred to a gender transition pathway too fast. Hilary Cass, who led an independent review of gender identity services for children and young people, said there was “insufficient evidence” to give her any firm advice on the routine use of puberty blockers. She has directed the National Health Service to “include young people eligible for hormone treatment into a formal study protocol.”
In Finlandgender experts have expressed concern that some patients prescribed drug treatments did not meet the strict entry requirements outlined in the so-called Dutch protocol. In the 1990s, Dutch gender specialists started laying the foundations for gender-affirming health care for minors. Described as a “meticulous and prudent approach”, it was devised by clinicians and painstakingly documented, from the late the 90’sThrough 2012.
As foreseen, the Dutch Protocol laid down a set of criteria for suitability for treatment. There should be a documented onset of gender dysphoria in early childhood, an increase in gender dysphoria after changes in puberty, absence of significant psychiatric comorbidity, and demonstrated knowledge and understanding of the consequences of medical transition. Treatment with puberty blockers can only be started from the age of 12. Interventions with clearly irreversible effects, including sex hormones and surgery, are only available at the age of 16 and 18, respectively. Should patients go through the transition process, all young people will be provided psychotherapy Through.
Finland was one of the first countries to adopt the Dutch Protocol for Pediatric Gender Medicine. However, in 2015, Finnish gender specialists noticed that most of their patients did not meet the relatively strict requirements of the Dutch Protocol to be eligible for drug treatment.
Doctors in other European countries also noted that the guidelines were not strictly followed, effectively taking into account what could be considered unauthorized treatment of many more minors – especially girls – than had been foreseen by the Dutch experts who drew up the original protocol.
Ultimately, this has led health authorities in Finland, Sweden and the UK to undertake systematic reviews of evidence for the benefits and risks of hormonal interventions. Subsequently, the findings of these reviews suggested that studies cited in support of hormonal interventions for adolescents have “very low” certainty. This in turn led to the placement of severe restrictions on access to hormones. It also raised the idea that such interventions are still in an “experimental” stage.
According to European health authorities and medical experts, there is de facto none yet medical compliance for the use of pharmaceutical and surgical procedures in minors with gender dysphoria.
In a article published in February this year in the Netherlands, the author concludes that “more research on gender reassignment among young people under the age of 18 is urgently needed”, referring in particular to the importance of investigating the long-term effects of medicalized transgender care.
The remarkable thing about the article is that it quotes extensively from one of the original members of the Dutch team of research clinicians who pioneered the use of puberty blockers in children with gender dysphoria more than twenty years ago.
Certainly, the Dutch have generally been more cautious – even than their European colleagues – in using interventions such as puberty blockers. Many Dutch doctors practice “watchful waiting” before proceeding with treatments.
Moreover, recent data analyzed by Dutch clinicians has made them think about how watertight even the Dutch protocol is. They noted that some patients who transitioned according to a strictly adhered to version of the Dutch protocol appear to have significant reproductive regret, body shame and sexual dysfunction upon monitoring. December 2022, these preliminary findings were presented by Dutch experts at the World Professional Association for Transgender HealthWPATH Symposium.
A common claim by Americans who oppose state restrictions on gender-affirming care for minors is that Sweden, Finland, the Netherlands, and the UK have failed to abolish hormonal interventions, and therefore lawmakers who push the boundaries are likely going against what European health authorities recommend. Moreover, voices in the American affirmative medicine movement point to Europe no ban on gender-affirming care for minors. It is true that Europeans do not ban such care, and so lawmakers in the US pursuing a ban are contrary to European recommendations. But this only tells part of an evolving and layered story.
At the risk of generalizing, the American approach offers more autonomy minors, in which the medical institution primarily affirms a child’s statement that he or she is trans. This affirmative model immediately removes some guardrails placed by, say, the Dutch Protocol, resulting in a potentially flawed lack of medical “protection”.
A growing number of countries in Europe do not practice “gender affirmative care” for minors in the same way that America does. In fact, Europe has been moving in a different direction than the US for several years now, as Europeans are more reserved in treating children with gender dysphoria. Essentially, the message increasingly emanating from European gender experts is that until there is reliable long-term evidence that the benefits of gender reassignment in young people outweigh the risks, it is prudent to limit most medical interventions to strict clinical research settings.