The Observatory's call
The Call of the Observatory of ideological discourses on children and adolescents: impacts of medical practices on children diagnosed as "gender dysphoric
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I - The Context
The evolution of the diagnosis of "gender dysphoria" in children and adolescents over the last few years is very disturbing: over the last ten years, requests for sex reassignment in this age category have increased exponentially depending on the country (1).
What should professionals working with children and young people, educationalists, doctors or psychologists, understand about the recent explosion of this demand or even claim?
Is it only the freedom of speech on the subject of "transidentity" that has allowed the phenomenon to grow to such an extent? Or does the sometimes very offensive and divisive activism of certain militant LGBTQI associations - potentiated by social networks - not lead to political pressure on young people and their families?
We are witnessing the emergence of ideological discourse on the "gender transition" of minors, ideological in that it pre-empts any debate: the slightest doubt about practices is immediately qualified as "transphobic", whereas the best interests of the child are at stake, particularly with regard to the irreversible medical consequences on the child's body (see below).
The Observatory's Appeal essentially concerns the protection of the child and the preservation of its physical and psychological integrity. It is precisely on this point that it is urgent to alert politicians (Ministry of Health, Ministry of National Education, Secretary of State for Child Protection) and the National Council of the Medical Association.
In fact, the "gender dysphoria" of children and adolescents bears witness both to an intimate question asked by a child or adolescent and to the way in which children and adolescents become a sounding board, or even an instrument of the social body that immediately validates their request.
Young people explain that they feel they belong to the other sex and see it as the answer to their malaise.
Would medical practices therefore give in to the injunction of new social norms without any possible debate, without concerted reflection between the various professionals working with children, without elementary observation of the precautionary principle?
Is it not permissible, without being branded with the anathema of "transphobia", to first question this malaise of young people in need of an identity and prey to all sorts of anxieties?
II - The symptomatic case of the documentary "Little girl
The documentary Petite fille, by Sébastien Lifshitz, broadcast on Arte in December 2020, and which follows another film, Girl, by Lukas Dhont, released in 2018, revealed to the general public this very sensitive subject of "gender dysphoria".
This subject of the gender "transition" envisaged in a young child is linked to the vulnerability of the child and the distress of families facing this issue. This film presents a little boy's desire to become a girl as a non-debatable state of affairs without taking into account the complexity of the family, even though the construction of the child's identity is consubstantial with the environment in which he evolves.
In this documentary, we are presented with a child, Sasha, aged 8, whose mother reports that he has expressed (very early on) the desire to become a girl 'like her' when he grows up, which is interpreted as 'becoming a woman'. In other words, when the child expresses his dream of becoming like his mother, the response is that of a medical treatment, authorised and even recommended, which would begin at an early age:
At first, the child's entourage, including the school, is invited to consider, in words and in deeds, Sasha as a little girl and no longer as a little boy.
Puberty blockers will be prescribed even before puberty, to prevent secondary sexual characteristics from taking hold.
Hormones of the other sex may be offered to him before he reaches the age of majority (from 14 in France).
Surgical interventions will be possible, with the parents' agreement, before the age of majority.
In our opinion, this sequence of events raises several crucial questions:
1. Documentary or docu-fiction? The staging of the medical protocol
The militant bias of the documentary raises questions. We hear only one point of view (rarely Sasha's in the end, rather his mother's) and no other professional who normally works with a child is interviewed: pediatrician, psychologist, teachers, etc.
Even more astonishing is the course of treatment by the specialised centre that Sasha's mother consults. Indeed, either Petite fille is a biased, committed, staged creation, which should then be presented as a "documentary-fiction" (2) made up of inaccuracies, caricatures and ellipses, and denounced by Robert Debré's specialised consultation as not representing the reality of their work; or this documentary is realistic and, in this sense, it seems very worrying to us to discover that a diagnosis of "gender dysphoria" can be made from the very first interview by a child psychiatrist:
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without an interview alone with the child,
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without the child ever having met a psychologist before being referred to one of the specialised French centres known for their doctrinal approach
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without the child psychiatrist meeting both parents,
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without any particular investigation (complete psychological assessment: projective tests, questionnaires, look at schooling, questions to other adults who know the child),
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without the child saying more than a few sentences,
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without even letting the child answer the questions put to him or her.
This is the director's view of the problem and it is this (partial and biased) view that is shown to the general public. This is the medical protocol that the film-maker reproduces.
If one compares it with more common diagnoses, with far less medical consequences, one realises that the process is strangely much stricter:
In order for a child to benefit from third-party testing for dyslexia, a dossier must be submitted to the MDPH, including a speech and language assessment, a psychological assessment and a paediatric report.
For a child to be diagnosed with ADD/ADHD and receive appropriate medication, he or she needs a medical recommendation and a neuropsychological assessment before even getting an appointment with a child psychiatrist, exclusively in a hospital, who will be the only one able to prescribe metylphenidate (better known as Ritalin) the first time AND thereafter.
The film, which implies a thoughtful and oriented editing, shows that, at the second appointment with the child psychiatrist, two or three months later, the child has still not been seen alone, he has still not benefited from the slightest psychological investigation, whereas, on the other hand, an appointment with the endocrinologist is going to be made the same day in order to prepare the protocol of sex change.
What is it about? To propose puberty blockers and to allow Sasha to keep his procreative capacities despite this (3), either by stopping the treatment that inhibits his puberty for the time necessary to collect spermatozoids (but this option seems less favoured by the doctor), or by an in vitro maturation of the testicles, all this "explained" in a few words to an eight year old. It is therefore already planned that 8-year-old Sasha will enter a process of "gender transition" which will lead to a radical change in his appearance, implying his future castration and consequently his permanent sterility.
The implementation of these first protocols for children (understood in the sense of the International Convention on the Rights of the Child, as being under 18 years of age) is beginning in several countries to generate legal proceedings by some adults who have undergone these treatments before coming of age and who have subsequently begun a "detransition". These plaintiffs argue that the protocols were put in place when they were children and therefore did not have the capacity to understand their implications (Bell/Tavistock judgment) (4) and therefore to give real informed consent to these protocols.
One can believe that Sasha dreams of being a girl; one doubts even more that he understood what puberty blockers were, what taking such a treatment implied in terms of renunciations and complications for the rest of his life, and one can be sure that he cannot conceive the reality of an ablation of his genital apparatus, the sexual use of which is still unknown to him, just as much as the sexuality of the adult.
With regard to medical ethics, we are forced to note a double transgression (of the device as presented by the director):
The absence of listening to the parents and especially to the child before making the diagnosis of "gender dysphoria".
The fact that interventions are carried out before puberty
2. The wrong object: the school of intolerance
Another very problematic aspect in the presentation of the facts raises, in our opinion, a failure of political ethics in addition to the problem of medical ethics: Sasha's school is immediately presented as a reactionary institution that resists the parents' request to have their child considered as a girl, because it is intolerant and hostile (this is the director's view through the parents' speech).
If we can understand the anger and frustration of Sasha's mother, we find it surprising that the good sense of the school is not praised:
First of all, educational institutions do not have to systematically accept particular requests from parents when these are not justified and recognised by a specialist (we note that the school accepts without any problem the protocol recommended by the Robert Debré hospital for the following school year). The school is obliged to respect the articles of the Civil Code relating to change of sex (art. 61-5 et seq. of the Civil Code) and change of first name (art. 57 and 60 of the Civil Code). If a pupil asks to be designated by a first name that does not appear on his or her civil status, the school is not obliged to comply with this request.
Secondly, it is to be welcomed that the school, a rare third party between the child and his parents, does not take the parents' statements at face value, and makes a dilatory response while waiting for a medical and psychological expertise. The school, as a public education service, representing the State, is the bearer of assistance to children, supposed to prevent and protect pupils and their freedom of conscience against any attempt at pressure, indoctrination (5) and violence, whether it takes place in the school or in the family.
Thus, it is clear that a political bias underlies the film's argument: caught up in a radical and militant rhetoric, the child is here transformed into a spokesperson for the trans cause in the face of a society obliged to obey without batting an eyelid the communitarian injunctions imposed by LGBTQI associations, on pain of impeding social progress and the rights of future citizens. This essentialist thinking, which determines and fixes sexual identities from childhood onwards, is profoundly contrary to the universalist and humanist principles that the school claims to uphold.
Teachers do not have the task of automatically acceding to the particular demands of each community to the detriment of the founding principles of the republican school, but on the contrary of protecting pupils from group pressures (religious, communitarian, political, etc.), of ensuring their physical integrity and of preserving their still-forming minds from sectarian or radical discourse or from external influences. It is in this spirit that the rules of our secular school system are inscribed, and it is on the basis of these rules that we could just as well interpret the reticence of Sasha's teachers towards his parents. Would we be so preoccupied by the school's refusal to accept the grievances of a fervent Amish pupil, even if supported by his parents?
III - The child, a developing being
It seems to us above all fundamental to be attentive to the developmental process specific to childhood and adolescence and to take time before any indication of medical treatment. The urgency to intervene is put on the account of the occurrence of pubertal transformations, which would modify the potential "success" of the surgical transformations to come.
On 3 December 2020, an opinion piece in The Guardian (6), highlighted the case of Bell, a former patient who regrets the gender transformation treatment she received as a teenager and argues that she was too young to consent to the medical treatment that began her female-to-male transition at this early stage in her life. In its 38-page decision cited above (7), the High Court in London concluded that children under 16 who are considering gender reassignment are not sufficiently mature to give informed consent to being prescribed puberty-blocking drugs. And for 16 and 17 year olds, she noted that although the (UK) law establishes a legal presumption of capacity to consent to medical treatment for them (8), she is aware that doctors might consider that they need to seek court permission (9) before starting treatment. It thus appears to be recommending that doctors should not start treatment for 16 and 17 year olds until they have obtained judicial advice. With this decision of the High Court, medical intervention for minors - and in particular for those under 16 - suffering from gender dysphoria will hopefully be more prudent.
1. Associated psychological disorders
Transidentity" in minors is presented by some as a right, a societal advance, which it would be discriminating to question, to consider as a symptom. However, our experience after a century of work in child psychology obliges us to consider it first of all as transitory or even symptomatic.
In adolescence in particular, the questioning of one's sexual identity is part of the questioning specific to this age. This adolescent quest, which is the usual driving force behind the maturation process essential to the subjective construction of the future adult, is now likely to find a mode of nomination that social networks establish as subjective truth. The technical-medical offer largely relayed by social networks and communitarian propaganda deny and would like to abolish this fundamental stage of subjective construction.
The increase in requests calls into question their supposed coherence and above all the univocal response that is given to them. This recent increase (less than 10 years) may have been encouraged by two very different but not necessarily incompatible factors:
the subjects concerned by questions about their sex finally feel authorised to express their distress thanks to greater social tolerance towards them
a large proportion of these requests come from a societal phenomenon (10), where "trans-identity" appears to be a response to a deep-seated malaise in adolescence, a radical, medicalised response that would resolve the difficulties once and for all.
It is on this second point that we wish to draw attention. Indeed, it appears that since the desire for "gender transition" is no longer considered as a psychopathological entity by the new version of the DSM, it is no longer considered as a symptom of a vulnerable psychic structure, even though these young people have a very large number of associated psychiatric disorders: anorexia, autism, depression, psychotic disorders, traumas linked to sexual aggression, etc.
2. A child is not a miniature adult
Our questioning is not about "transidentity" as such, nor about its diagnosis or its aetiology, but about the continuity, which seems too obvious in the militant discourse around this issue, between childhood, adolescent and adult disorders.
Indeed, a child - and even an adolescent - is not an adult: he is a developing being, his neuronal system is in the process of maturing, his cognitive and intellectual capacities are immature, his psychic functioning is labile, his suggestibility to adult discourse is high, his life experience is limited. To sum up, the psychopathology of the child is singular, the nosographies differ between children, adolescents and adults, so we cannot apply the same criteria or the same range of decisions.
On the other hand, puberty is not only a physical phenomenon but also a process of development and psychological maturation, involving psychic reorganisation, allowing the individual to become more of a "subject" when this stage is sufficiently successful. Conversely, puberty and, more broadly, adolescence is a period of great psychological risk, and we have all known for a long time how important this part of life is for the appearance of psychiatric pathologies.
3. The child's request ?
It seems crucial to us to question the request, supposedly made by the child, to change sex.
We know how the child is influenced by the discourse of adults and peers. This does not call into question their ability to think for themselves, but to deny the external suggestions, sometimes of influence, would be bad faith.
Without even trying to discuss the fact that the child 'feels' that he belongs to the other sex, we point out that the principle of the implementation of an irreversible transformation that would begin before and during puberty and the process of adolescence is not self-evident.
Numerous studies on this subject show that the majority of children with questions about their sexual identity and gender criteria will not continue their transformation after puberty (85%) (11). Given this data, why is it that once dysphoria is diagnosed, a protocol is immediately planned for several years involving meetings with endocrinologists, predictions of the maturity of the birth sex organs, surgical plans, etc.?
IV - Damage to the child's or adolescent's body
1. Alleged psychological benefits
Some psychiatrists systematically brandish an allegedly major suicidal risk in this young population, in order to disqualify as having criminal consequences all behaviours that are cautious and question the radical nature of the treatment, or that simply suggest the need to take time.
Thus, the father of a young girl who has decided to undergo a sex change testifies to the way in which he is asked, each time he questions the urgency of the treatment, "Sir, would you prefer a dead girl or a living boy? " (12). This formula, regularly repeated by various interlocutors, holds hostage this father who is summoned to choose between being a good father or a bad "transphobic" father, who is moreover responsible for the supposed suicide of his child (13).
It is important to stress, however, that:
That the studies that claim that there is such a risk are limited and controversial (14), as they cannot demonstrate that other factors are not involved. They are not based on any scientific mechanism such as control groups or longitudinal studies
We can see a beneficial effect of hormone treatment at the time, but we do not know what happens in the following years.
That the risk of suicide is indeed greater in the trans population, but that even in adults, even after the social and physical transformations have been carried out.
Finally, even if this treatment seems relevant in certain cases, it turns out that the reality of regrets is obvious in certain "detransitioning" subjects (15).
2. Puberty inhibitors
Puberty blockers (16), which allow the non-appearance of secondary sexual characteristics, are presented as having an apparently reversible effect once they are stopped. To date, doctors have few studies when they are administered between the ages of 12 and 16.
On the other hand, studies show short- and medium-term side effects in children:
Moderate effects :
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moderate effects: headaches, hot flushes,
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abdominal pain,
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Vaginal bleeding in girls,
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weight gain
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mood changes,
More marked effects:
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decrease in bone density (1% per month),
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risk of depression
These puberty blockers, combined with antagonistic hormones, can lead to permanent sterility, even if the genitals are preserved. It seems very surprising to imagine that a child or adolescent is able to renounce, for the rest of his or her adult life, the possibility of conceiving a child.
Finally, puberty in humans does not only correspond to the access to adult genitality, but it is simultaneously a period of intense psychic reorganisation that contributes to the process of subjectivation: every adult knows to what extent this period of his or her life is the foundation of his or her personality, sexual orientation, discovery of his or her body and genital pleasures, the necessary separation from parental figures, etc.
The question is lively: can we, without this experience, ensure that the individual develops in such a way as to know what he or she really wants? The question of real life experience is major and cannot be second-guessed. Ethics imposes these questions on us, which are currently very lively as regards consent, the possibility of deciding freely when one is still living, as is the case for every child, under the authority of adults to whom knowledge is lent.
3. The antagonistic hormones
Hormone therapy in connection with a sex change is not without health risks.
Estrogens are not recommended in cases of high blood pressure, diabetes, epilepsy, lupus, liver problems, severe migraines and otosclerosis. They entail long-term risks: increased percentage of strokes, venous or even arterial thromboembolic accidents, metabolic problems with hypercholesterolemia, gallstones and weight gain.
The metabolic and vascular risks of synthetic progestins are added to those of oestrogens and lead to an increase in meningiomas secondary to treatment with chlormadinone acetate or nomegestrol acetate, progestins frequently prescribed.
As far as testosterone is concerned, the effect is definitive in terms of virilisation, particularly hairiness and voice. The existence of numerous side effects requires a thorough medical examination before any prescription, as well as biological monitoring: arterial hypertension and risk of myocardial infarction, hypercholesterolemia, venous thromboembolism, hypercalcemia, weight gain, and caution in the case of thrombophilia, migraine sufferers, diabetics, epileptics, and people with liver failure, among others.
Mood swings, aggressiveness and impatience are frequently noted during treatment.
According to a 2018 study (17), transgender women are almost twice as likely to develop venous thromboembolic disease. This risk increases even more with age. As regards the risk of having a stroke caused by a thrombus, the odds were 9.9 times higher in transgender women than in the control group.
4. Surgery
Surgery is undoubtedly cumbersome, risky and highly imperfect (18). Depending on the country, it is possible before the age of majority. This is the case in France, even if it seems to be little practised at the moment. It would be necessary to know the number of operations performed on minors with "gender dysphoria" since these surgical interventions are mutilating (mastectomy in girls in particular, removal of the testicles in boys).
It is clear from all this that in the current context, we are dealing with medical experiments on children, which is formally prohibited and contrary to medical ethics (the primum non nocere of the Hippocratic oath)
V - Common sense recommendations
It is obviously not a question of leaving a child alone to face his or her real distress in a gender conflict. While the child's suffering must obviously be heard, welcomed and supported, adults must, for their part, ensure the protection of children, sometimes to the detriment of the immediate satisfaction of their desire. Waiting for a solution often seems like unbearable suffering, especially as it is added to the initial distress. And yet we all know very well that waiting allows reflection without haste, introspection detached from the influences of the environment, it also allows one to go beyond the critical moments and to continue one's development, one's personal evolution. Psychic and somatic are intimately linked, and there is never a unilateral and immediate answer to a psychic problem. It is therefore essential in any approach to preserve the possibility of a long period of time, which is currently abused by the idea of a supposed medical emergency, and to know how to wait for the age required to ensure that these subjects are capable of discernment
1. On the medical level
It seems to us very worrying and problematic to treat subjects in the making by denying them access to a stage of development that is essential to their psychological construction. The best interests of the child, linked to its physical and cognitive immaturity, should forbid us to intervene in its body in any way that does not fall within the scope of a vital emergency or care essential to its health. Verbal, family and individual therapies should take precedence throughout childhood and adolescence in order to help the child find specific answers to his suffering (and not to propose a systematised medical protocol) by preserving or opening up the possibility of doubt about his problems.
We recommend :
Multidisciplinary public health studies carried out in hospital departments, secondary schools and high schools in order to show the quantitative importance of "gender dysphoria
Serious medical and psychiatric studies and research, without conflict of interest or ideological aims, must be undertaken to gain a better understanding of this new and very young population, to determine the physical and psychological impact of this type of treatment in adults before applying it uniformly to children and adolescents, to observe the impact of the family environment but also of recent societal influences.
It would be appropriate, as the United Kingdom has done and as other countries are beginning to think about (United States, Sweden, Switzerland), to submit this question to a Committee of Reflection and Ethics composed of psychiatric and legal experts, but also of people concerned with child protection, so that we, in France, can legislate on this attack on the body of the minor.
Finally, the creation of long investigation consultations and/or specialised psychotherapies independent of hospitals, neutral consultation places independent of any ideological hold, carried out by specialised personnel with multi-criteria training (medical, psychological, sociological, legal, etc.) adapted to these problems, in order to welcome these families in questioning and often in crisis, and having to account for their work before the appropriate jurisdictions. This task cannot be limited to medical acts consisting of signing authorisations for treatment carried out by endocrinologists, however efficient they may be, as can be seen in many psychiatric services dedicated to gender dysphoria.
2. The role of the school
Trusting the educational community
In any case, the school must never become a place where society can force its way in with threats or anathemas on the school community: we therefore strongly reject the proposed approach of addressing these issues through injunctions or the shadow of sanctions on teaching teams.
Moreover, the treatment of these problems is eminently complex and certainly irreducible to a single rule or a systematic response: each case is by its very nature a special case and calls for genuine consultation of all the adults who surround and accompany the child - parents, teachers, doctors, psychologists.
This consultation can only take place in a climate of trust, not mistrust: the most appropriate measures must be discussed freely between the various protagonists, without going through legal processes on the subject, at the risk of unnecessarily exacerbating tensions. It seems to us to be essential in such circumstances that the institution trusts the educational community to work together with the families and pupils concerned.
To conclude
On the one hand, there is a desire to de-psychiatrize "gender dysphoria" and at the same time child psychiatry is being called upon for a diagnosis that will probably lead to a treatment: puberty blockers and/or hormonal treatments that are prescribed to minors who do not "feel" they belong to their biological sex. The diagnosis being necessary for the recognition of the harm suffered and the opening of "rights".
What we are witnessing is a reconsideration of the discourse on childhood, guided by ideologies that translate into new diagnostic categories and the treatments that accompany them, treatments that certainly already exist but not in this framework where they can be considered experimental.
With a redefinition of human rights, it is the notion of inclusion that is imposed at all levels of society and particularly at school. The school must adapt to all pupils, it must create facilities for all pupils according to various and sometimes unobjectifiable categories. It is no longer the pupil who has to adapt to a model that is valid for all (universalist and republican) but the school that has to take into account all the particularities of its pupils at the risk of having to face the disagreement of parents (and their respective associations). But once again, these new norms are only effects of discourse.
There is a gap between these discourses and the clinical practices which are to be understood on a case-by-case basis and which are much more complex and contradictory than one would suggest.
Could we not think that "gender dysphoria" as defined in the DSM is more of a "political programme" like ADHD (19)? There is a passion for assessment and diagnosis in order to label children. And with each labelling there is a risk of producing protocols or even a new language or a vademecum (cf. transphobia) in order not to stigmatise the children who fall into these categories (autistic, ADHD, trans...). But isn't this reducing these children to necessarily fixed identities? Is there not a risk of making these child-identities the standard bearers of the adults' cause? What is projected onto children by society and the disorder that runs through it, by the crisis of culture?
It is important to take care of the child, i.e. to give him or her the possibility of growing up while protecting him or her from adult projections, so as not to confuse the language of adults with that of the child.
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NOTES:
According to Jean Chambry in his conference of 3 February 2021 at the Cercle Freudien, ten years ago when the CIAPA (Centre Intersectoriel d'Accueil pour Adolescent) opened in Paris, there were about ten requests per year, in 2020 it is more like ten requests per month (only for the Ile de France region).
(2) As is the case with Michael Moore's films for example, as he does not respect the codes of the documentary contract, cf. Lipson, D. (2015). Michael Moore and the new documentary contract: from info-argument to info-tainment. Revue française d'études américaines, special 145(4), 142-158. https://doi.org/10.3917/rfea.145.0142
(3) The documentary does not appear to show that the child and her mother were fully informed of the consequences of the choice of medical transition in terms of their ability to have children. If Sasha were to become a trans woman, she could not under current French law have children using her gametes. Indeed, on her own, she would not be able to use them (even with medical surgery, she would not get a female body allowing her to bear children). If she were in a relationship with a biological woman, she could only use her gametes through MAP. However, MAP is currently only possible in France for heterosexual couples. If she were in a couple with a biological man, she could only use his gametes by resorting to GPA, which is prohibited in France.
(4) These implications were clarified as follows by the High Court in London on 1 December 2020 in Bell v. Tavistock, [2020] EWHC 3274: (i) the immediate consequences of the treatment in physical and psychological terms; (ii) the fact that the vast majority of patients who take puberty blockers go on to take cross-sex hormones and are therefore on the road to much more extensive medical interventions; (iii) the relationship between taking cross-sex hormones and subsequent surgery, with the implications of that surgery ; (iv) the fact that taking opposite-sex hormones may well lead to loss of fertility; (v) the impact of taking opposite-sex hormones on sexual function; (vi) the impact of choosing this treatment on future and lifelong relationships; (vii) the unknown physical consequences of taking puberty blockers; and (viii) the fact that the evidence base for this treatment is still very unclear (free translation).
(5) Article L141-5-2 of the Education Code
(7) High Court of London on 1 December 2020 in Bell v. Tavistock, [2020] EWHC 3274
(8) Section 8 of the Family Law Reform Act 1969
(9) Possibility created by Re W (Medical Treatment: Court's Jurisdiction) [1993] Fam. 64
(10) As discussed by Dr Lisa Littman, in a study of the influence of social networks on sudden gender dysphoria. Cf. Lisa Littman: Rapid Onset Gender Dysphoria in adolescents and young adults: A study of parental reports, 2018.
(11) See Philosophy Thesis, Devita Singh, A Follow-up Study of Boys with Gender Identity Disorder, Toroonto. Without intervention, the majority of dysphoric children come to terms with their biological sex at puberty and realise that they are simply gay. But if you put them on blockers, that doesn't happen. "Dr. Susan Bradley.
(12) Written testimony from a father who for the moment has remained anonymous but is willing to testify openly.
(13) On this subject see this article https://www.transgendertrend.com/suicide-by-trans-identified-children-in-england-and-wales/. This article by Professor Michael Biggs (Sociology, Oxford) on the suicide rate of trans-identified young people, tends to show a) that although trans-identity can be an aggravating factor, it is nevertheless far less than anorexia and depression and b) that it cannot be considered without taking into account the link between autism and trans-identity (autism being in itself an aggravating factor for suicide).
(14) Studies that have been rejected, are incomplete or extrapolate the results. Cf. https://medicine.yale.edu/news-article/26859/, but also the surveys carried out for the Bell vs. Tavistock Clinic judgment and the survey of the Swedish documentary Trans train.
(15) Cf. Bell vs Tavistock but also testimonies of adults. Also this Swedish documentary Trans Train which relates the testimonies of transgender people who share their questions and even their criticisms regarding medical treatments
(16) Cf. Vidal, for example the sheet on Decapeptyl, puberty inhibitor.
(17)https://pubmed.ncbi.nlm.nih.gov/30073551/
(18) Testimony of a trans man: https://quillette.com/2020/10/06/forget-what-gender-activists-tell-you-heres-what-medical-transition-looks-like/
(19) T. Garcia-Fons, "The Denial of Childhood", forthcoming in Solving the Mental Health Puzzle: Charting a Course from Mental Disorders to Humane Helping, USA, 2021.