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ATtransgender teenagers:
Is the wind starting to turn?

To view the original article, clickhere. French translation Deepl.

By Becky McCall and Lisa Nainggolan

April 26, 2021


One step led to another. This is the message of Keira Bell, a 24-year-old Briton who lives daily with the regret of having made the transition to male sex in adolescence. She was given puberty blockers after a few appointments at a gender clinic, before switching to injectingtestosterone. At the age of 20, she had suffered a doublemastectomy.


On December 1, 2020, Bell won a case in the High Court against theGender Identity Development Service(GIDS) from the Tavistock and Portman National Health Service (NHS) Foundation Trust, London, saying clinicians should have asked her more about the transition decision before starting medical treatment. GIDS is the only institution that treats people under 18 with gender dysphoria within the NHS.

In summary, the High Court hasdecided that young peopleunder 16 suffering fromgender dysphoria- i.e. people whose sex at birth is opposite to the gender with which they identify - cannot give informed consent to treatment with puberty blockers, drugs that aim to interrupt puberty normal.

The decision also encourages clinicians to seek court permission before treating anyone with dysphoria under the age of 18 with "affirmative" medical therapy (i.e. puberty blockers and transgender hormones, such as testosterone, for a transition to male sex orestrogenfor a transition to the female sex) if there is a risk that the patient does not fully understand the long-term implications of the therapy.

This 36-page High Court judgment upended the model of affirmative medical treatment for adolescents with gender dysphoria in the UK; the decision is currently under appeal.

Developmental Arrest: Are puberty blockers the start of a one-way street?



Of note, GIDS performed a study that showed no change in quality of life, psychological function, or degree of gender dysphoria in 44 children who took puberty blockers for up to 3 years [1]. The study also showed adverse effects of the treatment: suppression of bone mineral density and growth. And nearly 100% of children taking these agents continued to take transgender hormones, contradicting GIDS claims that puberty blockers work as a "pause" button to give children more time to think about their options. ; rather, the results suggest that the children were indeed on a one-way path to medical transition.

The next step is taking transsexual hormones, which is associated with several irreversible changes, including deepening of the voice, facial hair growth, clitoral growth in girls taking testosterone, as well as the possibility ofinfertilityand sexual dysfunction in girls and boys. Long-term side effects includeosteoporosis, thromboembolic events, cardiovascular diseases and malignancies, among others.

Many then turn to surgery - as Keira Bell did - particularly so-called "upper" surgery, which involves a double mastectomy for a woman transitioning to a man, or an augmentation breast for men in transition to women. In the UK, these operations are restricted to people over the age of 18, but in the US, double mastectomies have been performed on children as young as 13 years old [2, 3].

"I was a miserable girl who needed help. Instead, I was treated like an experiment," Bell says,telling his story on Persuasion. "As I matured, I recognized that gender dysphoria was a symptom of my general misery, not its cause. Five years after I began my medical transition to becoming a man, I began the process of detransitioning. The aftermath of what happened to me were profound: possible infertility, loss of my breasts and inability to breastfeed, atrophied genitals, permanently altered voice, facial hair."

Bell's victory in the UK High Court is considered a historic decision and, like what has happened in other European countries, indicates that the tide may be starting to turn regarding the way in which a minor suffering from gender problems can be treated by the medical profession.

A new type of patient: Tardive gender dysphoria, which mainly affects girls.



Will Malone, MD, is an assistant professor of endocrinology practicing in Twin Falls, Idaho, who says there is little evidence to support hormonal interventions for people younger than 18 with dysphoria. gender. In 2020, Malone was one of the clinicians and researchers who formed the Society for Evidence-Based Gender Medicine (SEGM), a non-profit organization that now has at least 100 physician members.


Mr Malone told Medscape that he became interested in this issue because he started getting calls from primary care doctors who said they were seeing cohorts of friends - teenage girls - who identified like men, often grouped together. "Some girls were very distressed. Some were asking for hormones, some weren't. The primary care doctors wanted to know what to do."

According to Mr. Malone, this phenomenon was very different from the gender dysphoria he had heard about in medical school or during his training, which mainly affected adult men who wanted to change their sex, or gender dysphoria. classic genre appearing in childhood, where young children (mostly boys) reported feeling trapped in the wrong body.

The vast majority of young people with gender dysphoria today are adolescents who suddenly express disgust for their birth gender, and 70% of them were born female. Many of them have comorbidities such as anxiety,attention deficit hyperactivity disorder, the spectrum featuresautisticand thedepression, explains Ms. Malone, which must be taken into account.

This new presentation - which has been called late-onset, adolescent, or rapid-onset gender dysphoria - is now seen in all gender clinics in the Western world, and the number of cases has risen sharply. A recent US study found a 4000% increase (more than 40 times) since 2006 [4], and similar large increases were observed in Finland [5], Norway [6], the Netherlands [7] , Canada [8] and Australia.

The London AIDS clinic has seen the number of referrals see a 30-fold increase in the last ten years - and again, these were mostly teenage girls who said they now identify as boys.

According to Mr. Malone, there is no credible scientific explanation to explain why we have gone from a predominance of boys to a predominance of girls presenting with gender dysphoria at the time of puberty.

Sabine Hannema, MD, from the Department of Pediatric Endocrinology at Amsterdam UMC, the Netherlands, treats transgender children. She told Medscape that the number of referred cases has indeed increased over the past decade and that the sex ratio of the children she sees has changed, with relatively higher numbers of transgender boys (assigned as female to birth) in recent years.

Stephen Rosenthal, MD, is a pediatric endocrinologist at the University of California, San Francisco, who treats transgender youth. He told Medscape that he thinks the concept of late onset is a parental notion. "Based on our experience in clinical practice, what seems like a putative quick start from a parent's perspective - because they've only just heard about it - might not [come] out of nowhere but something which the child has lived with for some time - but which does not reveal itself until adolescence."

Nevertheless, he recognizes that there is still a lot to discover.

Does social contagion play a role?



Numerous press articles have reported on groups of teenage girls, oftenin schools, who now claim to be transgender. Many people involved in the care of these children are increasingly concerned about the possible role of social contagion in the genesis and spread of this phenomenon.

Ms Hannema said she is aware of the concern that some children, exposed to certain media, may mistakenly believe that their non-specific emotional or bodily distress is the result of their transsexuality. She refers to a recent study on this subject, in which the Amsterdam clinic participated [9].

“The implicit result is that these people will resort to gender-related medical interventions and come to regret them when they realize that they are in fact not transgender,” observes Ms Hannema. However, she notes that other factors may explain the association between media coverage and increased service requests, and that regret rates have historically been very low.

Joshua Safer, MD, of Mount Sinai Hospital in New York, is an Endocrine Society spokesperson on transgender issues and says treatment of young transgender people is already conservative.

"We don't do any medical treatment on anyone before puberty. For most of the kids that we're talking about in their mid-teens, we use a very conservative approach, which is puberty blockers...because they're basically reversible."

"The approach has been used for a long time for precocious puberty, so we have data from adults who were treated years ago with these regimens. Our confidence in their safety is quite high," he adds.

Asked by Medscape about its reaction to the UK High Court's finding that virtually all children taking puberty blockers are switching to transgender hormones, Mr Safer said the fact that people are not withdrawing is a sign that doctors succeed in identifying suitable children to receive this treatment.

Hannema, too, claims that in her clinic the majority of young people taking puberty blockers do actually switch to trans hormones, although she reports a slightly lower percentage than the UK GIDS. “In a recent study [10], we reported that 87% of adolescents who started puberty suppression subsequently started gender-affirming hormone therapy,” she told Medscape. In total, 6% stopped puberty blockers and 3.5% no longer wished to undergo gender affirmation treatment. The others were still on puberty blockers at the last follow-up.

Safer adds, "I've certainly heard the argument that [puberty blockers] might 'put them to sleep' [kids with gender dysphoria], but I can tell you that our ability to brainwash kids is pretty low. We think we're doing a better job of vetting people, and fewer and fewer people are opting out."

Yet there is no doubt that more and more people - from the worlds of psychiatry, psychology and endocrinology, as well asparents of children with gender dysphoria- publicly express their concerns about the speed with which medical treatment can be given in some countries, often with a minimum of psychological counseling beforehand.

In fact, it was the parent of a 16-year-old with autism seeking treatment at GIDS – Mrs A – who initiated the UK legal action, which Keira Bell turned to. subsequently attached.

Detransitioners: Little research on those who regret their transition


Despite claims by physicians who treat transgender youth that the regret rate is low, there is evidence that an increasing number of "detransitioners" - typically young people in their twenties who have undergone medical procedures and, in many cases, sex reassignment surgery, bitterly regret their decision. It is difficult to determine the exact number of those who regret their transition, as there has been no formal research on this, butmany claimthat in itself is reason enough to hit the pause button on this practice of "affirmative" medical therapy, especially among those under 18.

James Caspian is a British psychotherapist experienced in counseling transgender adults. He told Medscape in 2019 that he first became interested in the topic when a gender reassignment surgeon he knew in Serbia told him he had patients coming back, asking that their transitional surgery is "reversed". At first it was a trickle of patients, but like Caspianexplains in a recent UK podcast, this surgeon has now reported more than 70 “regret” patients in his practice alone.

Areddit threadfor people in transition currently has more than 17,000 members, and a facility in Sweden, the Lundstrom Gender Clinic, offers atrauma therapy for people in transition.

Asked about people who might regret their transition, Safer told Medscape, "It's absolutely true that you can find people who regret their choice."

However, he nuances, "the data does not seem to suggest that the majority of these people say that their sexual identity is necessarily different; rather, they regret medical treatments for various reasons. is the lack of acceptance by society which is the main reason why they regret their decision." 

And he claims that those who regret their decision represent less than 1% of those treated. “I can speak from my specific experience,” he says when pressed to cite published research to back up the figure. "I've cared for hundreds of transgender people and I have a single digit number [of those] who have regretted medical treatment, so that's where my figure of less than 1% comes from."

Hannema tells Medscape, "As clinicians working in this field, we are very mindful of the risk of regret throughout the assessment and treatment process. It will be important to not only continue to provide adequate counseling before undertake such interventions, but also to observe whether regret rates increase in the face of greater media attention and more dismissals."[10]

Even transgender adults are sounding the alarm


Many transgender adultsshootalsothe alarm bellbecause they know the burden of lifelong hormone treatment and the many complications associated with gender-affirming surgeries.

In the UK, the dialogue has reached a critical juncture since Keira Bell's victory in court, and the mainstream media is now openly covering all aspects of the discussion. And while the conversation in the United States is still markedly different, there are signs that the situation may be about to change.

Last year, Wall Street Journal contributor Abigail Shrier's book Irreversible Damage: Teenage Girls and the Transgender Craze sparked an uproar when it was first published. The Economist listed it as one of its "Books of 2020".

Explaining the reasons that led her to investigate this phenomenon in aarticle ofDaily Mail, Ms Shrier says she was 'haunted' by one question: What's wrong with these girls? “Their distress is real, but their self-diagnosis is flawed – it is more the result of encouragement and suggestion than psychological necessity,” she writes.

"Many adolescent girls who identify as transgender don't actually want to be men. They just want to run away from womanhood like a house on fire, with their mind set on flight and not on a particular destination. They feel estranged from their bodies. and the changes brought about by puberty:acne, menstruation and breast development, and uncomfortable male attention....It's a story Americans need to hear."

Some therapists interviewed by Shrier believe these young girls are actually suffering from a type of "body dysmorphia" not unlikeanorexia nervosa, while others worry that they are repressed lesbians and that some sort of internal "homophobia" is fueling their desire to be a man.

Malone, the Idaho endocrinologist, says Shrier - who interviewed more than 200 people including doctors, psychotherapists, parents, transsexuals, transgender "influencers" and transgender adults - wrote "a book meticulously documented and indispensable".

Asked by Medscape what he thinks of Shrier's book, the Mount Sinai Safer endocrinologist says it's "based entirely on the perspective of fearful parents who worry about their children being brainwashed." .

Endocrine societies and transgender charities join appeal over UK High Court verdict

Reaction to Shrier's book has paralleled reactions to the UK court ruling, including from organizations supporting transgender people, who say this long marginalized group has only recently gained the confidence to speak out and get treatment.

These groups claim that many children and their parents are now left stranded, unable to access medical treatment after being told that puberty blockers and transgender hormones are the only hope for relieving gender dysphoria. (Actually aanother judgment has been renderedsince then that parents may, in cases where children are already receiving puberty blockers, consent to the continuation of this therapy if they demonstrate that they fully understand the risks and benefits).

But the appeal of the Bell decision in June will be the most important decision. The US Endocrine Society was granted permission to intervene in this appeal, along with GIDS.

Asked about the Keira Bell case, Ms Hannema said: "I think rather than involving a court to decide whether treatment is appropriate, the mental health provider who carried out the diagnostic assessment of the adolescent - and who therefore knows their specific situation and development - should assess the adolescent's capacity to give informed consent, in collaboration with the multidisciplinary team."

Rosenthal, too, emphasizes the importance of an interdisciplinary approach to the care of these children. "The Endocrine Society's number one that the determination of gender dysphoria, whether present or not, should be made by a qualified mental health professional...It has no changed," he said.

“Some people may really have rapid-onset gender dysphoria, but there are also people who have found in gender dysphoria a solution to another problem and therefore are not really dysphoric This is where we depend on the expertise of our mental health specialists,” he adds.

In this legal battle with Britain's GIDS and the Endocrine Society, psychiatrist David Bell (no relation to Keira Bell), who recently retired from GIDS, andTransgenderTrend, a UK group representing concerned parents of children with late-onset gender dysphoria, are in the opposite camp. Both were allowed to intervene to defend the December 1 decision.

The outcome of this appeal in the High Court in London, which will be heard over two days from June 23, could have huge ramifications for the care of transgender children around the world, including in the United States. , where there are now around 65 specialist clinics offering "positive medical care" to dysphoric children.

Endocrine Society guidelines based on study


Safer is on the World Professional Association for Transgender Health (WPATH) Standards of Care Review Committee. The most recent WPATH standards of care [11], published in 2012, state the following: “Adolescents may be eligible to start feminizing/masculinizing hormone therapy, preferably with parental consent. In many countries, 16-year-olds are legal adults for medical decision-making and do not need parental consent." They add, "Hormone therapy should only be provided to people who are legally capable of giving informed consent. This includes people who have been declared by a court to be emancipated minors."

Safe is also co-author of2017 guidelinesof the Endocrine Society for the treatment of gender-confused youth [12]. These guidelines were formally presented at the Endocrine Society Annual Meeting in March 2018.

Malone was there.

At this conference, the Endocrine Society - a highly respected organization - presented a set of guidelines for children that basically said, "Your job as endocrinologists is to medically affirm [gender dysphoric] adolescents with puberty blockers and transgender hormones,” he tells Medscape. 

Mr Malone says he was stunned when he first heard of these guidelines, but immediately thought: 'There must have been a massive change in the landscape, a landmark study that I somehow missed an amazing piece of evidence that says, 'Psychotherapy is out and affirmation is in'." But the evidence just wasn't there, he says.

The recommendations are based on a single uncontrolled study from the Netherlands (the so-called "Dutch study", published in 2014 [13]), which Malone said was of low quality.

"The Dutch study looked at children with gender dysphoria from infancy and, although it found that psychological functioning was comparable to that of the general population after gender affirming interventions, it was is a very different group of children [from] older teenagers who have no documented childhood history of gender dysphoria and are the cause of the increased numbers,” explains- he.

He further notes that the Dutch protocol, which includes hormonal and surgical interventions, was never designed or tested for this group. In fact, Dutch clinicians excluded cases of gender dysphoria in adolescence, considering them ineligible for medical interventions.

Malone adds that because gender identity is much more fluid in these newer cases and identity continues to change, medical interventions that cement a certain physical appearance are dangerous - and that may be the best reason to reevaluate the therapeutic approach.

No questions allowed: Follow the advice; the debate is most polarized in the United States


Dr. Malone says he is shocked by the Endocrine Society's guidelines. "If you start puberty blockers at Tanner stage 2 [precocious puberty, as recommended], and then put these children directly on intersex hormones, they are almost certain to be infertile, along with many other irreversible changes ."

What he found equally disturbing was the complete absence of any lively discussion of this controversial topic at the meeting.  

"Endocrinologists should be aware that the Endocrine Society's 2017 guidelines on gender dysphoria [11] are one-sided and the evidence referenced therein is of low quality. I urge concerned clinicians to review primary studies that are used to justify irreversible interventions,” he says.

According to Malone, the Endocrine Society is failing in its duty to its members because "although it claims that the evidence supporting its recommendations is weak, it promotes them as if they were a "standard of care", which is not the case".

The debate over how best to deal with transgender minors is probably more polarized in the United States than just about anywhere else in the world.

Arkansas comes fromadopt a law, which is due to come into effect in July, banning certain types of treatment for transgender youth. This law threatens with loss of license any medical professional who provides puberty blockers, transgender hormones or gender-affirming surgery to minors, and exposes them to legal action from patients who later regret their intervention. At least 16 other US states are considering similar legislation.

On the other hand, parents who try to obtain psychological help for their children before proceeding with hormone treatment often find onlytherapists who "affirm" their child's transgender identityand recommend that they start taking puberty blockers or transgender hormones.

Safer told Medscape, however, that with the exception of Arkansas (once the ban is enacted), the standard of care for a child with gender dysphoria does not differ between states.

“The approach of the facility is that the child comes in and has a mental health screening and there are sober conversations. If they are prepubescent there is no intervention. If they're in their mid-teens, the intervention, if there is intervention, would be puberty blockers, which are reversible, so it's a very conservative approach, actually," he says. .

Asked about Malone, the SEGM and their concerns about the hasty assertion of young transgender people, Mr Safer replied: "This is a relatively small group that has been making the same arguments for a number of years, and it is very outside the mainstream. It's not that there's a debate within organized medicine, where there's an equal number of people on both sides. Dr. Malone is outside of those arguments; [ he] is not in the mainstream."

Mr Safer also advises not to "confuse the conservative conclusions of the existing literature with the absence of data".

Mr Malone says he would like to challenge the Endocrine Society to discuss at one of its meetings whether the 'affirmative' model of care is the most appropriate for children with dysphoria of gender.

"Pediatric care of gender dysphoria is still a relatively new and evolving area of clinical practice, in which there are inevitably many unknowns and gaps in evidence. As scientists, we have been educated to put in question: nullius in verba [take no one at their word]. If we reflect on our own practice, peer review, rigorous testing, and high-quality data collection all improve patient outcomes. None of 'between us doesn't have [all] the answers, but adherence to basic scientific principles will bring us closer to them,' observes Dr Malone.

Also asked about the SEGM, Mr Rosenthal said he did not wish to comment specifically on the organisation, but added: "I totally support high quality research. I couldn't be more supportive of the concept. implied by the name of this group [Society for Evidence-Based Gender Medicine]."

However, Rosenthal qualifies: "There is an inevitable imbalance between the amount of information we know at the moment and the desire to provide compassionate care based on long-term data. We do not have long-term data term, but that does not mean that we should do nothing, which is not a neutral option.

“We have a significant amount of published research that is of high quality and supports our current clinical practice guidelines,” he argues.

“These interventions are experimental”;
maturity is not reached until the age of 25.



Proponents of positive medical therapy for gender dysphoria often claim that these children have a high rate of suicidal ideation and that restricting their access to hormone therapies (and surgery) would put them at risk.

"Data shows that if you're not supportive of children, you're more likely to have mental health issues," says Dr. Safer. "And if you support them, the data shows you'll have fewer mental health issues, so the strategy is to support them, or 'affirm' them. That's the standard of care within the medical community."

But there is also little concrete evidence that transitioning improves mental health. And because the concept of late-onset gender dysphoria is relatively new, there are very few studies on this specific group of patients.

But the British GIDS study [1] provides some interesting data on this point. The study was meant to mimic the "Dutch" study, but found no changes in psychological functioning, quality of life or degree of gender dysphoria in adolescents with late puberty. The authors concluded that "larger, longer-term prospective studies...are needed to more fully quantify the harms and benefits of pubertal suppression in gender dysphoria and better understand the factors influencing outcomes." "

New studies published this month by the UK's National Institute for Health and Care Excellence (NICE) onpuberty blockersand thetranssexual hormonesdrew similar conclusions. They note that no studies compared transgender hormones or puberty blockers with a control group, and that all follow-up periods for transgender hormones were relatively short.

Other historical data suggests that the transition has little effect on mental health.

Aswedish studyof adults who have undergone a medical and surgical transition revealed that deaths bysuicidewere still nearly 20 times higher in this group than among cisgender people (identifying with their birth sex) [14]. Astudy carried out in the Netherlandsgave similar results [15].

"There is no evidence that the transition reduces the number of suicides if you look beyond ten years, and it would seemeven as suicide rates increase aonce the honeymoon phase of the transition is over,” says Malone, who emphasizes the importance of proper psychological assessment and treatment for any suicidal tendencies.

Indeed, in the Swedish documentaryTrans Train 2, Danuta Wasserman, MD, PhD, professor of psychiatry and suicidology at Stockholm's Karolinska Institutet and world expert on suicide, agrees.

“People are always advised to avoid making life-altering decisions when they are depressed, anxious or grieving. We know that many transgender people suffer from anxiety and deep depression. What help do they have? need? The evidence clearly shows, in suicide prevention, that we need conversational therapy for young people before, during and after puberty."

Malone therefore welcomes the judgment rendered in the Keira Bell case.

"The UK decision, from an endocrinology perspective, is that these interventions are experimental, that young people cannot understand the implications of placing puberty blockers, trans-sex hormones and surgical operations - and that makes sense based on our understanding of brain development,” he explains.

"Cognitive maturity does not occur before the age of25 years", explains Mr Malone, adding that this is the reason why, for example, it is very rare for a woman under the age of 25 to have a hysterectomy, except in a life-threatening situation, even if she asks for it. , because the doctors will feel that she is not mature enough to know whether or not she will want children in the future.

It's also for this reason that Malone dislikes the "informed consent" model of gender affirmation that he says currently exists in the United States. Besides the many clinics that specialize in gender affirmation, there are multiple other hormone providers for young people with gender dysphoria, such asPlanned Parenthood, which now provides transgender hormones to anyone who identifies as transgender, provided they sign an agreement stating that they are aware of the medical risks associated with hormone therapy.

Parlor reviews? Doctors become skeptical and develop ethical stress


Many who support and practice the positive medical treatment of transgender children have accused those who oppose this position of being"salon reviews",claiming that until you have one of these distressed children "in front of you" you cannot begin to understand what is best for them.

However, several clinicians who have treated these children are themselves beginning to express regret.

Angela Sämfjord, MD, a child and adolescent psychiatrist at Sahlgrenska University Hospital in Gothenburg, Sweden, established a clinic for children and adolescents - the Lundstrom Gender Clinic - in 2016. Two years later she resigned due to his own fears about the lack of evidence for hormonal and surgical treatments.

She tells Medscape, "There's a lot of tension between some gender clinic approaches and the trans community. Patients found it difficult to accept that they needed to undergo a full mental health assessment before being referred to a medical treatment. The parents said no one ever discussed that other issues...may be involved in the child's dysphoria."

The teens referred had many psychiatric symptoms, Ms Sämfjord says, and she realized gender dysphoria was only part of a complex problem. She also noticed that psychiatric symptoms came first, followed by gender dysphoria in adolescence.

"I felt like we couldn't separate these things. By focusing only on gender dysphoria, we risked missing other things," she tells Medscape. Of his patients, 90% had another psychiatric diagnosis in addition to gender dysphoria; 80% had two or more. Depression and anxiety were the most common, and 20% had an autism diagnosis when they arrived at the clinic; about 50% had symptoms of autism.

"When I realized the complexity [of these cases] [...] and that medical professionals are still expected to accept gender-affirming treatments despite the lack of evidence we currently have, it attacked my conscience," she told the Trans Train 2 documentary in the fall of 2019.

"I was not ready to take the risk, as a doctor, of causing harm to these patients. I took the consequences and resigned," says Sämfjord.

Similarly, many UK GIDS staff have now left the service, saying they were afraid to raise patient safety concerns for fear of reprisals from their superiors, as has been reported.previously reportedMedscape.

Sue Evans is a psychotherapist who resigned from GIDS because she felt "deeply concerned" about the accelerated medical treatment of young people.

She was a witness in the Keira Bell case, and told Medscape at the time, "The judges said the children needed to understand the whole process of treatment, from starting puberty blockers to switching to transgender hormones The onset of blocking therapy cannot be said to be distinct Although a child may understand the concept of loss of fertility, for example, this is not the same as understanding how it will affect his adult life."

Finland takes a firm position; the United States is a "perfect storm" of inappropriate transitions.



As evidenced by doctors who were interviewed for the Swedish Trans Train documentaries, some Scandinavian countries have also begun to scrutinize the issue of gender dysphoria in children – and the best treatment for them.

In 2020, Finland became the first country in the world to publishnew guidelinesfor this group of patients when it concluded, similarly to the UK High Court, that there is a lack of quality evidence to support the use of hormonal interventions in adolescents with gender dysphoria.

These new Finnish guidelines prioritize psychological therapy over hormone or surgical treatment and suggest different care plans for early-onset and late-onset childhood gender dysphoria. And Sweden comes frompublish a new guidelinewhich reflects a significant shift in focus for the diagnosis of gender dysphoria in minors, now emphasizing the need for a thorough mental health assessment. Recommendations on treatments based on puberty blockers and transgender hormones are expected later this year.

Malone points out that in terms of the priority given to psychological assessment, the United States (and to a similar extent Canada and Australia) currently lag behind the United Kingdom and Finland.

But he is pleased that in the UK and elsewhere doctors "are much more skeptical of the guidelines [than we are in the US], and that's music to my ears".

“Psychological assessment and treatment receives much less attention in the US than in the UK,” Ms Malone says. “There is also a much more aggressive schedule for the delivery of puberty blockers and hormones, so we have created the perfect storm of inappropriate transitions.

"Keira Bell's case was preventable. Clinicians should be aware that if you intervene without solid supporting evidence, there is a good chance that people will be harmed. The more people come forward, the more they will realize. .that's what's happening. The question is, "How much damage has to happen before people start noticing?"


1. Polly Carmichael, Gary Butler, Una Masic et al. Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK. PLOS One. February 2, 2021

2. Olson-Kennedy, Johanna, Jonathan Warus, Vivian Okonta et al. "Chest Reconstruction and Chest Dysphoria in Transmasculine Minors and Young Adults: Comparisons of Nonsurgical and Postsurgical Cohorts". JAMA Pediatrics 172, no. 5 (2018 May 1): 431.

3.Jamie E Mehringer1,Jacqueline B Harrison2,Kit M Quainet al. Experience of Chest Dysphoria and Masculinizing Chest Surgery in Transmasculine Youth. Pediatrics published online ahead of print February 3, 2021 Another Pediatrics on Thoracic Surgery.

4. “National College Health Assessment”: ACHA-NCHAs://

5. Finland: Kaltiala-Heino, Riittakerttu, Hannah Bergman, Marja Työläjärvi, and Louise Frisen. "Gender Dysphoria in Adolescence: Current Perspectives". Adolescent health, medicine and therapy Volume 9 (March 2018): 31-41.


7. Netherlands: Vries, Annelou L.C. de. "Challenges in timing puberty suppression for gender-nonconforming adolescents". Pediatrics 146, no. 4 (October 2020): e2020010611.

8. Canada: Zucker, Kenneth J. “Adolescents with gender dysphoria: Reflections on some contemporary clinical and research issues.” Archives of Sexual Behavior 48, No. 7 (October 2019): 1983-92.

9. Pang KC, de Graaf NM, Chew D et al. Association of media coverage of transgender and gender diverse issues with rates of referral of transgender children and adolescents to specialist gender clinics in the UK and Australia. JAMA Network Open 2020. Jul 1; 3(7):e2011161.doi:10.1001/jamanetw

10. Brik T, Vrouenraets LJJJ, de Vries MC, Hannema SE. Arch Sex Behav. 2020 Oct;49(7):2611-2618. doi: 10.1007/s10508-020-01660-8

11. Eli Coleman et al. "Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People", 7th version, WPATH, 2012

12. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102:3869-3903

13.Annelou L.C. de Vries,Thomas D. Steensma,Theo A.H. DoreleijersMD, PhDet al. Puberty Suppression in Adolescents With Gender Identity Disorder: A Prospective Follow-Up Study.The Journal of Sexual Medicine;Volume 8, Issue 8, August 2011, p. 2276-2283

14. Dhejne C, Lichtenstein P, Boman M, et al. Long-term follow-up of transsexual persons undergoing sex reassignment surgery: A cohort study in Sweden. PLoS One. 2011;6:e16885

15. Asscheman H, Giltay EJ, Megens JA, et al. A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Eur J Endocrinol. 2011;164:635-642.

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