Some European countries are changing how they approach gender care in children and young adolescents experiencing gender incongruence/dysphoria. There is a move away from medicalized care to placing more emphasis on providing psychosocial support for this younger age group.
Here's what you need to know.
UK Cass Review: Evidence Weak
On April 10, 2024, the final report of the Cass Review was published following 4 years of meta-analyses of the available literature. The review, carried out by pediatrician Dr Hilary Cass, was prompted by a soaring rise in demand for gender identity treatments, such as puberty blockers, among children and teens in the UK. It found "remarkably weak evidence" to support gender treatments for children. "For most young people," the review said, "a medical pathway will not be the best way forward to manage gender-related distress."
The review called for gender services to operate "to the same standards" as other health services for children and young people, with "a holistic assessment" that includes screening for neurodevelopmental conditions, such as autism, and a mental health assessment.
In March, England's National Health Service said it will no longer prescribe puberty blockers to children at gender identity clinics owing to a lack of evidence to support their safety or effectiveness. Instead, they will only be available as part of clinical research trials.
On April 18, Scotland's only gender clinic announced that it had also paused prescribing puberty blockers to persons younger than 18 years, and new patients who are minors will no longer receive other hormone treatments. In a statement, it said that referrals to pediatric endocrinology for the prescription of puberty-suppressing hormones have been paused, but anyone referred will be given "the psychological support they require" while care pathways are reviewed in line with the Cass Review findings.
The Puberty Blocker Controversy
Puberty blockers are used to delay the changes of puberty to allow more time for young people with gender incongruence/dysphoria to explore their gender. They were first proposed for this purpose in the mid-1990s by clinicians in the Netherlands. The intervention they developed became known as the Dutch Protocol, which set out treatment criteria that became standard practice and influenced many countries to prescribe puberty blockers.
Clinicians in many countries in Europe and around the world continue to regard puberty blockers as an effective treatment for young people with gender dysphoria.
Transgender Europe (TGEU) is a trans-led nonprofit for the rights and well-being of trans people in Europe and Central Asia. It represents 200 member organizations across 50 countries. Its policy officer, Deekshitha Ganesan, told Medscape Medical News: "Puberty blockers help young trans people who are undergoing puberty temporarily delay the process, facilitate exploration of their gender identity, and help in making decisions about medical transition.
"It is a reversible process, allows for simultaneous social transitioning, and simply helps make sure that there are no permanent physical changes brought on by puberty that cannot be undone," Ganesan explained. "Restricting access to blockers is not a neutral approach. It can take a serious toll on the mental health of young trans people who are forced to undergo puberty. In contrast, research has shown the mental health of those who have access to trans-specific healthcare, like puberty blockers, is improved and comparable to that of cisgender peers of their age."
But Ireland-based Stella O'Malley, a psychotherapist and director of Genspect, an organization that advocates for a nonmedicalized approach to gender dysphoria, is concerned. She told Medscape Medical News: "Advances in medical science have yet to ascertain exactly what happens when a human's sexual development is halted in this manner. To date, we have very little knowledge. However, the research suggests that bone development is impaired and cognitive functioning is impaired as a consequence of taking puberty blockers."
Ganesan disagrees. "There is ongoing research on the effects of puberty blockers, and current evidence does not demonstrate that blockers are harmful. Lack of evidence of long-term effects cannot be a good reason to restrict healthcare access."
Calls for More Change in Europe
Dr Alexander Korte is a child and adolescent psychiatrist at Ludwig Maximilian University of Munich. He would like to see changes in Germany's approach to the use of puberty blockers in children.
"The situation in Germany is still very confused. We will very soon have the clearly trans-affirmative guidelines which have been revised in recent years under the leadership of the German Society for Child and Adolescent Psychiatry [Psychomatics] and Psychotherapy. But at the same time, there are an increasing number of critical voices pointing to the lack of scientific evidence for the early medical intervention of concrete puberty-blocking treatment."
He said that puberty blockers don't give people time to think about their gender because most cases move almost immediately onto cross-sex hormones.
"I consider this therapy irresponsible because of the unclear data situation. If opposite-sex hormones are used after the puberty blockers, which is known to be the case in over 95% of children treated with GnRH [gonadotropin-releasing hormone] analogs, this leads to permanent infertility in addition to permanent impairment of the ability to experience sexuality," he said.
Finland-based pediatric gender medicine expert Dr Riittakerttu Kaltiala hopes the Cass Review will have a big impact on childhood gender care throughout Europe and elsewhere. "I find the Cass Review a most important and powerful evaluation of the current complex situation, and a solid base for planning care of children and adolescents presenting with gender-related distress," she told Medscape Medical News.
She said in Finland, puberty blockers can only be considered after a comprehensive multidisciplinary assessment in one of the two nationally centralized gender identity units for minors. She appreciates the Cass Review's emphasis on psychosocial interventions as a first line of treatment for gender-distressed minors. "This is much along the same lines as we work in Finland," she said.
Some Changing Practices in Europe
The Netherlands
In the Netherlands, where the Dutch Protocol originated, practice guidelines have not yet been revised. However, on February 15, 2024, the Dutch Parliament ordered that an investigation be conducted into the physical and mental health outcomes of children prescribed puberty blockers.
Norway
Norway's Healthcare Investigation Board (Ukom) recommended in 2023 that the Ministry of Health and Care task the Directorate of Health to revise the national professional guideline for gender incongruence in a way that is based on a systematic summary of knowledge. The Ukom report recommended that puberty blockers and hormonal and surgical gender confirmation treatment for children and young people should be defined as experimental treatment. Explicit new guidance from the country has not yet been issued.
France
France's National Academy of Medicine recommended in 2022 that the "greatest reserve" is required regarding the use of puberty blockers and/or transitioning hormones in children and adolescents. However, their prescription continues to be possible with parental authorization at any age.
Sweden
Sweden's National Board of Health and Welfare said in 2022 that the risks of puberty blockers and gender-affirming hormone treatments for persons younger than 18 years currently outweigh the potential benefits for the group as a whole. It added that treatment with hormones should continue to be given, but only within a research framework to further understand its impact on gender dysphoria, mental health, and quality of life in this age group. Hormones can also be given to this age group in exceptional cases, the board said.
Finland
Finland's Council for Choices in Health Care revised its guidelines in 2020 to prioritize psychosocial support over medical intervention but confirmed that initiation of hormonal interventions may be considered in a person before the age of 18 "if it can be ascertained that their identity as the other sex is of a permanent nature and causes severe dysphoria." The child's understanding of the significance, benefits, and disadvantages of the treatments must also be confirmed, and there must be no contraindications.
More Data From Europe
One of the studies that informed the Cass Review conducted a survey of European gender services for children and adolescents between September 2022 and April 2023.
It found that Greece, Luxembourg, and Ireland do not have gender services for children and adolescents.
Of the countries that responded to the survey, those that do have national or regional structured services for children and adolescents are Norway, Denmark, Finland, Northern Ireland, Spain, and the Netherlands. All services are publicly funded and are mainly located within tertiary or secondary care mental health, endocrinology, or pediatric departments.
Belgium, the Netherlands, and Spain have a minimum age requirement of 8, 9, and 14 years, respectively, for accessing their gender services. Other services that responded did not have a minimum age.
All services comprised multidisciplinary teams, with varied composition and organization.
Clinical practice in the services that responded to the survey is most commonly informed by the WPATH Standards of Care version 7 or 8 and Endocrine Society guidelines. But the Netherlands also uses country-specific guidelines, whereas Denmark and Finland base their services on national guidelines alone.
Referrals from mental health services are required in Finland, Northern Ireland, and Norway but are not necessary in the Netherlands, Denmark, Belgium, or Spain.
In-house psychosocial interventions were reported as limited by the services that responded. Interventions to suppress puberty require a diagnosis of gender dysphoria and stable mental health, with only Finland and Spain specifying a minimum age of 13 and 12 years, respectively. Variations exist among the services in the prescription of masculinizing/feminizing hormones, access to fertility preservation/counseling, and collection of outcome data.
https://www.medscape.com/viewarticle/europe-and-puberty-blocker-debate-2024a1000831
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