Par Annegret Böhme - 09/10/24
The professional society of child and adolescent psychiatrists is missing an opportunity to debate the treatment of gender dysphoria in young people.
Those who suffer from gender dysphoria can receive medical treatment from adolescence onwards: with puberty blockers, hormones and (usually from the age of majority onwards) surgery. The draft new treatment guidelines for Germany, Austria and Switzerland recommend these early interventions, which are considered established. However, they are increasingly criticised in professional circles. Few people, including doctors and therapists, but also the people affected and their parents, really know what they are talking about.
The main body responsible for this directive is the German Society for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy (DGKJP). For its regular congress, held this year in Rostock, it had scheduled a ‘technical debate’ on the subject. Supporters and critics of early medical intervention were invited to the podium: professors of child and juvenile psychiatry Georg Romer (Münster), Florian Zepf (Jena) and Veit Rössner (Dresden), as well as child and adolescent psychotherapist Sabine Maur. Romer and Maur are among the authors of the draft guideline, Romer as chairman of the committee that drew it up. The draft recommends early intervention. Firstly, to prevent the body from developing in an undesirable way, and secondly to adapt it to the gender experienced. Clinically, the treatment is well proven, and can reduce psychological problems and gender dysphoria, as well as increasing social acceptance. The testimony of those affected is central to the diagnosis.
Zepf and Rössner criticise this. They believe that there is no clear evidence for the recommended treatment of minors with puberty blockers and hormones. The draft guideline ignores publications from the last four years. The interventions, carried out during a sensitive phase of unfinished development, would have significant and lasting consequences. However, neither the lasting usefulness nor the long-term risks - particularly in terms of brain and bone maturation, fertility and sexuality - have been sufficiently studied. Many professors share this view and have commented critically on the project, calling for changes.
Public interest in Rostock is high. The five hundred seats in the auditorium were almost all occupied. However, at the time of the debate, the critics of the project were absent from the rostrum. Only Romer, Maur, and the moderator, Professor Christine Freitag, who is responsible for guidelines on the DGKJP board, were present. Zepf was seated in the audience, while Rössner was absent. The moderator hastily justifies these absences by the discussions that this subject is generating in the community. She dodged questions. Florian Zepf did not speak until after the official end of the session. ‘We thought we'd be able to express ourselves fairly,’ he says. But at the last minute, topics were imposed on him and Rössner, which they had to answer or not. What's more, he was only given seven minutes to speak. Rössner only had a few more, while Maur had a quarter of an hour and Romer more than twenty minutes. A ‘fair exchange of arguments’ was therefore impossible. Zepf concluded that the professional society did not want a debate. Freitag refused to comment.
The audience also got the same impression. There was a broad consensus on stage. The questions to be asked by the audience were projected at the start of the debate, but the most interesting ones were missing. In addition, Freitag's repeated refusal to answer questions about absences was disconcerting. Even when Romer asked the ‘critical thinkers’ to speak at the start of the debate, and Zepf headed for the microphone, Freitag interrupted him with a ‘Stop, stop!’, insisting that the order of the speeches be respected.
Some listeners raise crucial points: the drugs used to treat gender dysphoria in young people are not authorised for this indication. Can teenagers really understand the importance of wanting a child when they reach adulthood? The public asks questions, and the experts sometimes answer in detail, but not always completely. Romer admits that drugs are often used outside their official indications in children and adolescents, which is true since the drugs are mainly tested on adults. However, he does not answer the question of the specific indication. Puberty blockers are approved to treat other conditions such as cancer, but the long-term effects of using them to delay puberty in cases of gender dysphoria have not yet been studied.
Other important information was provided by a professor in the audience: an evidence-based S3 guideline was initially planned, but only a consensus-based S2k guideline was quickly adopted. The German Society for Psychiatry, Psychotherapy and Neurology (DGPPN), as well as the professional society of Swiss child and adolescent psychiatrists, have now rejected the draft guideline.
In Rostock, there would have been plenty to debate. For example, when Romer spoke of the threat to fertility posed by the treatment and the need to think about cryopreservation, although he admitted that the subject was ‘relatively new’. Twenty years ago, ‘nobody was concerned about it’. Why has it taken so long to interest experts? The question remains unanswered. At the end of the day, we still don't know exactly how the need for treatment is determined.
Some members of the professional society were astonished, while others were annoyed, after the debate was over. One participant remarked that this had never happened before at the congress. Internationally, there has long been an in-depth scientific discussion on the concept of diagnosis and treatment of young people with gender dysphoria, which underpins the German draft directive. For a long time, the dominant interpretation belonged to those who had developed it. But this is changing. In Scandinavia and the UK, the concept is now being questioned even by the doctors who originally applied it. Treatment recommendations are also moving towards a more cautious approach. According to Florian Zepf, the approach adopted in Germany has become a ‘marginal position’. He concluded somewhat strangely in Rostock: ‘The people concerned deserve an evidence-based directive. It would be unethical not to align it with the results of current, real research.
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