Policy change regarding hormonal treatment of minors with gender dysphoria at Tema Barn Children's Hospital - Astrid Lindgren.
 

Context
 

Hormone treatment for children and adolescents with gender dysphoria may consist of puberty blocking therapy initiated at the onset of puberty, and transgender hormones initiated at age 16. These treatments are controversial and have recently come under increased attention and scrutiny, both nationally and internationally. In December 2019, the SBU (Swedish Agency for Health Technology Assessment and Social Services Evaluation) published an overview of the knowledge base which showed a lack of evidence for both long-term consequences term of treatment, and for the reasons of the large influx of patients in recent years. These treatments can have significant and irreversible negative consequences such as cardiovascular disease, osteoporosis, infertility, increased risk of cancer and thrombosis. It is therefore difficult to assess the risk/benefit ratio for each patient and even more difficult for minors and their guardians to adopt an informed position on these treatments.
A high-profile court case in Britain shed light on this issue and, in a recent decision (December 1, 2020), established the overriding issues associated with puberty-blocking treatments. Furthermore, the judgment specifically establishes that it is highly unlikely, if not impossible, for an individual under the age of 16 to give informed consent to this treatment. For individuals between the ages of 16 and 18, the court finds it advisable to seek court approval before beginning hormone treatment, as such treatment should be considered experimental. Following this judgement, the National Health Service (NHS) halted the initiation of hormone treatments in new cases of people aged under 16, while recommending a thorough review of ongoing cases and actively treated. For patients between the ages of 16 and 18, it is recommended that the attending physician receive court approval before beginning transgender hormone treatments.

Executive decisions
 

§ In the light of the above, and on the basis of the precautionary principle, which should always be applied, it has been decided that hormonal treatments (i.e. puberty-blocking hormones and hormones intersex) will not be initiated in dysphoric patients under 16 years of age.
§ For patients between the ages of 16 and 18, it has been decided that the treatment can only be carried out in clinical trials approved by the EPM (Ethical Review Agency/Swedish Institutional Review Board). The patient should be given full information about the potential risks of the treatment and a careful assessment of the patient's level of maturity should be made to determine if they are capable of evaluating and consenting to the treatment.

§ These changes do not affect the continuation of psychological and psychiatric care within the BUP (public child and adolescent psychiatry) for patients under 18 years of age.
§ These changes apply from April 1, 2021.
For patients currently being treated with puberty blockade or transgender hormones, careful individual assessment to determine whether treatment should be discontinued or continued should be performed by the treating provider. When making this assessment, it is important to present appropriate information about the uncertainty of the state of the evidence regarding the long-term effects and potential risks of treatment, to enable patients and caregivers to make equally informed decisions. as possible as to the consent to a possible continuation of the processing. The degree of maturity and capacity for consent of young patients, as well as other indications, must be taken into account in these decisions.

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