(DeepL)
In many parts of the world, including Europe, many citizens and scientists are concerned about the recent surge of self-identified transgender minors (IGVM, 2022; Zucker, 2017). With laudable intentions, some healthcare professionals believe that there is little room to question this feeling. These professionals then propose, sometimes quickly, transaffirmative treatments that make it possible through hormone prescriptions and surgical operations to transform a body to make it resemble a body of the opposite sex. In the light of the latest studies and findings, this type of medical treatment is becoming increasingly questionable (Barnes, 2023; Eliacheff-Masson, 2022; Shrier, 2022).
As physicians, we wish to sound the alarm about what has become a serious public health problem. At present, transaffirmative care for minors is being called into question in many countries. In the UK (Cass, 2022), Sweden (SEGM, 2022) and Finland (Kelleher, 2023), transaffirmative treatments for minors have been re-evaluated and limited within the precise framework of scientific studies. In the United States, a majority of states have restricted access to gender-affirming treatment for minors, or are considering legislation to this effect (HRC, 2023). Of these, fifteen states prohibit care for minors based on gender affirmation. Under these bans, doctors who continue to provide care face major direct sanctions (Mallory et al., 2023). These changes are the result of a twofold realization. On the one hand, it has been established that, in these minors, the "trans" feeling is strongly favored, even induced, by social influences (Littman, 2018); it is therefore avoidable or reversible (Singh et al., 2021; Steensma et al., 2011). On the other hand, transaffirmative treatments are fraught with often irreversible consequences for physical, mental and social health (Biggs, 2021; Panagiotakopoulos et al., 2020; Ristori & Steensma, 2016), with no scientific evidence of significant improvement in the fundamental ill-being of the young person concerned (Carmichael et al., 2021; Clayton, 2023; Clayton et al., 2022; NICE, 2020, 2020b). In addition, studies and testimonies show the existence of physical, mental or social health problems prior to or concomitant with the "trans" experience in a majority of these young people (Kaltiala-Heino et al., 2015). These must therefore be assessed and treated before any physical intervention
As several studies have shown, these young people's feelings of gender dysphoria would often disappear spontaneously if their environment, social networks and a few caregivers didn't encourage them to persevere, but instead took the time to question their request (Ristori & Steensma, 2016). A psychotherapeutic approach, or even child psychiatric care, could help these young people to understand the source of their malaise and enable them to distance themselves from an often hasty project.
Social transition" is the phase when young people change their first names and pronouns to refer to themselves and to be referred to. He then adopts the gender stereotypes of the other sex and sees them recognized by those around him. This acceptance by adults is a form of conditioning that reinforces the change project on a daily basis. It is regarded as a transaffirmative treatment in itself, since it severely compromises later reconciliation with one's birth gender. Once such a transition has been initiated, the prognosis for reversibility is very low, with the majority of minors who have begun a social transition persevering (Olson et al., 2022; Zucker, 2020). Younger children take puberty blockers, while older children take cross-sex hormones. But this is not without consequences. There is still little research on the influence of these hormones, puberty blockers or cross hormones, on the physical health of young people, either in general or over the long term (Joint et al., 2018; Moreira Allgayer et al., 2023; Sudhakar et al., 2022). Nevertheless, there are some important findings. Puberty blockers administered in late childhood can cause osteoporosis (Biggs, 2021). Lack of libido, a side effect of this treatment, may lead to a physiological inability to experience sexual pleasure (Gil-Llario et al., 2021; Ley, 2021). Genitalia that remain prepubescent will make subsequent sexual transformation surgery difficult (van de Grift et al., 2020). Moreover, these operations are still too often a source of complications or re-interventions (Elfering, 2023; Mancini et al., 2021; Reed et al., 2015; Salgado et al., 2016). Some analyses have shown negative consequences for cognitive functioning (Anacker et al., 2021; Hough, Bellingham, Haraldsen, McLaughlin, Robinson, et al., 2017; Hough, Bellingham, Haraldsen, McLaughlin, Rennie, et al., 2017; Schneider et al., 2017; Staphorsius et al., 2015; Zucker, 2017). Hormonal treatments strongly increase the risk of permanent sterility (Cheng et al., 2019; Pang et al., 2020; Schwartz & Moravek, 2021). In girls receiving high doses of testosterone, side effects such as hair growth and voice changes are irreversible. Later, in adulthood, the risks of cardiovascular disorders and cancer increase (Alzahrani et al., 2019; de Blok et al., 2019; Getahun et al., 2018; Hanby et al., 2023; Hutchison et al., 2018). What's more, any medical intervention, whether aimed at the body or the mind, raises the question of the patient's informed consent. This issue is particularly complex when it comes to the care of minors. It has to do with the age and maturity of the patient, and his or her ability to understand the stakes, risks, vital urgency, co-morbidities and type of care to be administered. Are these children and adolescents capable of measuring the implications of these chemical and surgical treatments, their risks and side effects such as infertility or anorgasmia, and anticipating the costs and benefits of the final outcome? To the best of our knowledge, there is no reliable process or protocol for obtaining informed consent from minors for the treatment of gender dysphoria (Levine et al., 2022). Nous considérons donc inadéquates les prises en chargetransaffirmatives des jeunesexprimant un ressenti « trans » ; la transition sociale telle que décrite ci-dessus faisant partie de ces prises en charge inappropriées. We are alerting the medical authorities to the risks incurred by young people undergoing these trans-affirmative treatments. These aberrations call for urgent, enlightened guidance.
With regard to the treatment of minors who identify themselves as trans in Belgium, the current situation calls for rapid reflection and the urgent implementation of precise protocols that respect scientific evidence where it exists, and the precautionary principle when medicine cannot provide scientifically proven recommendations.
Authors:
Dr. Sophie Dechêne, child psychiatrist
Dr. Nicole Einaudi, child psychiatrist
Prof. Jean-Yves Hayez, Professor Emeritus at UCL, child psychiatrist
Dr. Beryl Koener, child psychiatrist
Dr. Jean-Pierre Lebrun, psychiatrist
Dr. Vera Schlusmans, general practitioner Signatories : Association Professionnelle des Psychiatres Infanto-Juvéniles Francophones Dr. Marie-Louise Allen, médecin généraliste Dr. Françoise-Marie Annet, pédopsychiatre Dr. Déborah Arys, médecin généraliste Dr. Naima Ben Addi, psychiatre infanto-juvénile Dr Anne Franchimont Beuken, médecin généraliste Dr Sylvie Boden, pédopsychiatre Dr. Françoise Bury-Lefebvre, pédiatre Dr. Jean Bury, interniste-hématologue Dr. Anne Calberg, psychiatre Dr. Fabienne Caluwaers, médecin généraliste Pr. Dominique Charlier, professeur émérite à l’UCL, psychiatre infanto-juvénile Dr Alexandre Cupa, pédiatre Dr. Ann d’Alcantara, professeur émérite à l’UCL, psychiatre infanto-juvénile Dr Clémence de Broglie, médecine physique et de réadaptation Dr Didier de Hemptinne, gynécologue-obstétricien Dr Anne de Radiguès-Delvaux de Fenffe, pédiatre Dr Isabelle Dagneaux, médecin généraliste Dr. Mila Danailova, pédopsychiatre Dr. Marie Deprez, neuropédiatre Dr. Michaël Detienne, pédiatre Dr. Dimitri Dourdine Mak, pédiatre Dr Caroline Frippiat, médecin scolaire Dr. Bernard Fourez, psychiatre Dr Anne Franchimont Beuken, médecin généraliste Dr. Nadine Francotte, pédiatre hémato-oncologue Dr. Stéphanie Gabriel, radiothérapeute Dr. Pierrette Gengoux, dermatologue-homéopathe Dr. Sophie Ghariani, neuropédiatre Dr. Françoise Godfroid, médecin de famille Dr. Marie-Agnès Hayez, pédiatre Dr Jacques Keutgen pédiatre Pr. Thierry Lahaye, retraité, chirurgie plastique Dr. Marie-Françoise Lorent, psychiatre infanto-juvénile Dr. Sophie Maes, psychiatre infanto-juvénile Dr. Nathalie Meertens, radiologiste Dr. Muriel Meynckens, psychiatre, thérapeute systémicienne Dr. Etienne Oldenhove, psychiatre Dr Jean Papadopoulos, pédiatre réanimateur Dr. Christophe Panichelli, psychiatre Dr. Emilie Poitoux, pédiatre Dr. Nathalie Sannikoff, pédiatre Dr. Georges Schmit, psychiatre Dr. Jean-Marc Scholl, psychiatre infanto-juvénile Dr. Chantal Van Cutsem, psychiatre infanto-juvénile Dr. Joelle Van Hees, pédiatre Dr. Didier Van Laethem, médecin généraliste Pr. Christine Verellen-Dumoulin, généticienne Dr. Emmanuelle Vrins, médecin généraliste Dr. Pierre Vrins, médecin généraliste Dr. Marie-Isabelle Wéra, psychiatre Dr. David Weynants, pédiatre
References
Alzahrani, T., Nguyen, T., Ryan, A., Dwairy, A., McCaffrey, J., Yunus, R., Forgione, J., Krepp, J., Nagy, C., Mazhari, R., & Reiner, J. (2019). Cardiovascular Disease Risk Factors and Myocardial Infarction in the Transgender Population. Circ Cardiovasc Qual Outcomes, 12(4), e005597. https://doi.org/10.1161/CIRCOUTCOMES.119.005597
Anacker, C., Sydnor, E., Chen, B. K., LaGamma, C. C., McGowan, J. C., Mastrodonato, A., Hunsberger, H. C., Shores, R., Dixon, R. S., McEwen, B. S., Byne, W., Meyer-Bahlburg, H. F. L., Bockting, W., Ehrhardt, A. A., & Denny, C. A. (2021). Behavioral and neurobiological effects of GnRH agonist treatment in mice-potential implications for puberty suppression in transgender individuals. Neuropsychopharmacology, 46(5), 882-890. https://doi.org/10.1038/s41386-020-00826-1
Barnes, H. (2023). Time to Think: The Inside Story of the Collapse of the Tavistock's Gender Service for Children. Swift.
Biggs, M. (2021). Revisiting the effect of GnRH analogue treatment on bone mineral density in young adolescents with gender dysphoria. J Pediatr Endocrinol Metab, 34(7), 937-939. https://doi.org/10.1515/jpem-2021-0180
Carmichael, P., Butler, G., Masic, U., Cole, T. J., De Stavola, B. L., Davidson, S., Skageberg, E. M., Khadr, S., & Viner, R. M. (2021). 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, 16(2), e0243894. https://doi.org/10.1371/journal.pone.0243894
Cass, H. (2022). INDEPENDENT REVIEW OF GENDER IDENTITY SERVICES FOR CHILDREN AND YOUNG PEOPLE – FURTHER ADVICE. In I. R. o. G. I. S. f. C. a. Y. People (Ed.).
Cheng, P. J., Pastuszak, A. W., Myers, J. B., Goodwin, I. A., & Hotaling, J. M. (2019). Fertility concerns of the transgender patient. Transl Androl Urol, 8(3), 209-218. https://doi.org/10.21037/tau.2019.05.09
Clayton, A. (2023). Commentary on Levine et al.: A Tale of Two Informed Consent Processes. J Sex Marital Ther, 49(1), 88-95. https://doi.org/10.1080/0092623X.2022.2070565
Clayton, A., Malone, W. J., Clarke, P., Mason, J., & D'Angelo, R. (2022). Commentary: The Signal and the Noise-questioning the benefits of puberty blockers for youth with gender dysphoria-a commentary on Rew et al. (2021). Child Adolesc Ment Health, 27(3), 259-262. https://doi.org/10.1111/camh.12533
de Blok, C. J. M., Wiepjes, C. M., Nota, N. M., van Engelen, K., Adank, M. A., Dreijerink, K. M. A., Barbe, E., Konings, I., & den Heijer, M. (2019). Breast cancer risk in transgender people receiving hormone treatment: nationwide cohort study in the Netherlands. BMJ, 365, l1652. https://doi.org/10.1136/bmj.l1652
Elfering, L. (2023). Outcomes of masculinizing gender-affirming surgeries: Towards personalised transgender care Vrije Universiteit Amsterdam]. Enschede.
Eliacheff, C. M., C. (2022). La fabrique de l'enfant transgenre. L’Observatoire.
Getahun, D., Nash, R., Flanders, W. D., Baird, T. C., Becerra-Culqui, T. A., Cromwell, L., Hunkeler, E., Lash, T. L., Millman, A., Quinn, V. P., Robinson, B., Roblin, D., Silverberg, M. J., Safer, J., Slovis, J., Tangpricha, V., & Goodman, M. (2018). Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons: A Cohort Study. Ann Intern Med, 169(4), 205-213. https://doi.org/10.7326/M17-2785
Gil-Llario, M. D., Gil-Julia, B., Gimenez-Garcia, C., Bergero-Miguel, T., & Ballester-Arnal, R. (2021). Sexual behavior and sexual health of transgender women and men before treatment: Similarities and differences. Int J Transgend Health, 22(3), 304-315. https://doi.org/10.1080/26895269.2020.1838386
Hanby, E., Gazarian, P. K., Potter, J., Jones, R., Elhassan, N., & Tan, A. S. L. (2023). "I liked just that it was a communal thing": Feasibility and acceptability of engaging with transgender and gender-diverse persons in a digital photovoice research study on commercial cigarette smoking risk and protective factors. Digit Health, 9, 20552076231169819. https://doi.org/10.1177/20552076231169819
Hough, D., Bellingham, M., Haraldsen, I. R., McLaughlin, M., Robinson, J. E., Solbakk, A. K., & Evans, N. P. (2017). A reduction in long-term spatial memory persists after discontinuation of peripubertal GnRH agonist treatment in sheep. Psychoneuroendocrinology, 77, 1-8. https://doi.org/10.1016/j.psyneuen.2016.11.029
Hough, D., Bellingham, M., Haraldsen, I. R. H., McLaughlin, M., Rennie, M., Robinson, J. E., Solbakk, A. K., & Evans, N. P. (2017). Spatial memory is impaired by peripubertal GnRH agonist treatment and testosterone replacement in sheep. Psychoneuroendocrinology, 75, 173-182. https://doi.org/10.1016/j.psyneuen.2016.10.016
HRC. (2023). Map: Attacks on Gender Affirming Care by State.
Hutchison, L. M., Boscoe, F. P., & Feingold, B. J. (2018). Cancers Disproportionately Affecting the New York State Transgender Population, 1979-2016. Am J Public Health, 108(9), 1260-1262. https://doi.org/10.2105/AJPH.2018.304560
IGVM, U.-. (2022). Personnes transgenres ayant fait une demande de changement de la mention officielle de leur sexe en Belgique – 2022 Données issues du Registre national https://igvm-iefh.belgium.be/sites/default/files/chiffres_personnes_transgenres_registre_national.pdf
Joint, R., Chen, Z. E., & Cameron, S. (2018). Breast and reproductive cancers in the transgender population: a systematic review. BJOG, 125(12), 1505-1512. https://doi.org/10.1111/1471-0528.15258
Kaltiala-Heino, R., Sumia, M., Tyolajarvi, M., & Lindberg, N. (2015). Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development. Child Adolesc Psychiatry Ment Health, 9, 9. https://doi.org/10.1186/s13034-015-0042-y
Kelleher, R. (2023). Finland Takes Another Look at Youth Gender Medicine https://genspect.org/finland-takes-another-look-at-youth-gender-medicine/
Levine, S. B., Abbruzzese, E., & Mason, J. W. (2022). Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults. J Sex Marital Ther, 48(7), 706-727. https://doi.org/10.1080/0092623X.2022.2046221
Ley, D. J. (2021). Does Affirmative Treatment Impair Sexual Response in Trans Youth?
Sexual health and orgasmic naivete in trans youth. https://www.psychologytoday.com/intl/blog/women-who-stray/202111/does-affirmative-treatment-impair-sexual-response-in-trans-youth
Littman, L. (2018). Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria. PLoS One, 13(8), e0202330. https://doi.org/10.1371/journal.pone.0202330
Mallory, C., Chin, M. G., & Lee, J. C. (2023). Legal Penalties for Physicians Providing Gender-Affirming Care. JAMA. https://doi.org/10.1001/jama.2023.8232
Mancini, I., Tarditi, D., Gava, G., Alvisi, S., Contu, L., Morselli, P. G., Giacomelli, G., Lami, A., Seracchioli, R., & Meriggiola, M. C. (2021). Feasibility, Safety, and Satisfaction of Combined Hysterectomy with Bilateral Salpingo-Oophorectomy and Chest Surgery in Transgender and Gender Non-Conforming Individuals. Int J Environ Res Public Health, 18(13). https://doi.org/10.3390/ijerph18137133
Moreira Allgayer, R. M. C., Borba, G. D. S., Moraes, R. S., Ramos, R. B., & Spritzer, P. M. (2023). The Effect of Gender-Affirming Hormone Therapy on the Risk of Subclinical Atherosclerosis in the Transgender Population: A Systematic Review. Endocr Pract. https://doi.org/10.1016/j.eprac.2022.12.017
NICE. (2020). Evidence review: Gender-affirming hormones for children and adolescents with gender dysphoria. https://segm.org/sites/default/files/20210323_Evidence%2Breview_Gender-affirming%2Bhormones_For%2Bupload_Final_download.pdf
NICE. (2020b). Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria. . https://segm.org/sites/default/files/20210323_Evidence%2Breview_GnRH%2Banalogues_For%2Bupload_Final_download.pdf
Olson, K. R., Durwood, L., Horton, R., Gallagher, N. M., & Devor, A. (2022). Gender Identity 5 Years After Social Transition. Pediatrics, 150(2). https://doi.org/10.1542/peds.2021-056082
Panagiotakopoulos, L., Chulani, V., Koyama, A., Childress, K., Forcier, M., Grimsby, G., & Greenberg, K. (2020). The effect of early puberty suppression on treatment options and outcomes in transgender patients. Nat Rev Urol, 17(11), 626-636. https://doi.org/10.1038/s41585-020-0372-2
Pang, K. C., Peri, A. J. S., Chung, H. E., Telfer, M., Elder, C. V., Grover, S., & Jayasinghe, Y. (2020). Rates of Fertility Preservation Use Among Transgender Adolescents. JAMA Pediatr, 174(9), 890-891. https://doi.org/10.1001/jamapediatrics.2020.0264
Reed, H. M., Yanes, R. E., Delto, J. C., Omarzai, Y., & Imperatore, K. (2015). Non-grafted Vaginal Depth Augmentation for Transgender Atresia, Our Experience and Survey of Related Procedures. Aesthetic Plast Surg, 39(5), 733-744. https://doi.org/10.1007/s00266-015-0523-7
Ristori, J., & Steensma, T. D. (2016). Gender dysphoria in childhood. Int Rev Psychiatry, 28(1), 13-20. https://doi.org/10.3109/09540261.2015.1115754
Salgado, C. J., Nugent, A. G., Moody, A. M., Chim, H., Paz, A. M., & Chen, H. C. (2016). Immediate pedicled gracilis flap in radial forearm flap phalloplasty for transgender male patients to reduce urinary fistula. J Plast Reconstr Aesthet Surg, 69(11), 1551-1557. https://doi.org/10.1016/j.bjps.2016.05.011
Schneider, M. A., Spritzer, P. M., Soll, B. M. B., Fontanari, A. M. V., Carneiro, M., Tovar-Moll, F., Costa, A. B., da Silva, D. C., Schwarz, K., Anes, M., Tramontina, S., & Lobato, M. I. R. (2017). Brain Maturation, Cognition and Voice Pattern in a Gender Dysphoria Case under Pubertal Suppression. Front Hum Neurosci, 11, 528. https://doi.org/10.3389/fnhum.2017.00528
Schwartz, A. R., & Moravek, M. B. (2021). Reproductive potential and fertility preservation in transgender and nonbinary individuals. Curr Opin Obstet Gynecol, 33(4), 327-334. https://doi.org/10.1097/GCO.0000000000000729
SEGM. (2022). Summary of Key Recommendations from the Swedish National Board of Health and Welfare (Socialstyrelsen/NBHW) https://segm.org/segm-summary-sweden-prioritizes-therapy-curbs-hormones-for-gender-dysphoric-youth
Shrier, A. (2022). Irreversible Damage: The Transgender Craze Seducing Our Daughters. Regnery publishing.
Singh, D., Bradley, S. J., & Zucker, K. J. (2021). A Follow-Up Study of Boys With Gender Identity Disorder. Front Psychiatry, 12, 632784. https://doi.org/10.3389/fpsyt.2021.632784
Staphorsius, A. S., Kreukels, B. P., Cohen-Kettenis, P. T., Veltman, D. J., Burke, S. M., Schagen, S. E., Wouters, F. M., Delemarre-van de Waal, H. A., & Bakker, J. (2015). Puberty suppression and executive functioning: An fMRI-study in adolescents with gender dysphoria. Psychoneuroendocrinology, 56, 190-199. https://doi.org/10.1016/j.psyneuen.2015.03.007
Steensma, T. D., Biemond, R., de Boer, F., & Cohen-Kettenis, P. T. (2011). Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study. Clin Child Psychol Psychiatry, 16(4), 499-516. https://doi.org/10.1177/1359104510378303
Sudhakar, D., Huang, Z., Zietkowski, M., Powell, N., & Fisher, A. R. (2022). Feminizing gender-affirming hormone therapy for the transgender and gender diverse population: An overview of treatment modality, monitoring, and risks. Neurourol Urodyn. https://doi.org/10.1002/nau.25097
van de Grift, T. C., van Gelder, Z. J., Mullender, M. G., Steensma, T. D., de Vries, A. L. C., & Bouman, M. B. (2020). Timing of Puberty Suppression and Surgical Options for Transgender Youth. Pediatrics, 146(5). https://doi.org/10.1542/peds.2019-3653
Zucker, K. J. (2017). Epidemiology of gender dysphoria and transgender identity. Sex Health, 14(5), 404-411. https://doi.org/10.1071/SH17067
Zucker, K. J. (2020). Debate: Different strokes for different folks. Child Adolesc Ment Health, 25(1), 36-37. https://doi.org/10.1111/camh.12330