How can we care for transgender people, and in particular children who do not identify with the gender assigned to them at birth? The question has continued to agitate the political and medical spheres for several years. In the United States, Donald Trump has just suddenly brought the subject back to the forefront. He even made it one of the very first themes of his inauguration speech – to hammer home that the United States would no longer recognize only “two sexes, male and female” defined at birth.
Even if the phenomenon remains very minority, even marginal, the number of people treated has increased in recent years almost everywhere in the world. In France, for example, requests for surgical operations among adults increased threefold between 2011 and 2020 (from 536 to 1,615) and increased from 6 to 48 among those under 18, according to a document from the Haute health authority published in 2022. This increase, the cause of which remains unexplained, fuels fantasies and risky hypotheses, such as that of “social contamination”, not proven. But in France, as in most other developed countries, the debates focus on minors. In any case, this new medical demand is accompanied by an increasing range of care, with more consultations and treatment in specialized clinics.
Therefore, the question of adapting the care pathway arises. How should we support children who say they are transgender? Should we facilitate the prescription of puberty blockers, so-called “gender affirmation” hormones and gender reassignment surgery, or on the contrary limit or even ban them? The HAS was tasked with studying the available scientific data in order to update its recommendations. Its highly anticipated report is due to be released in the coming weeks.
To date, hormone blockers are prescribed without age conditions, provided that minors have parental authorization. These drugs, on the market for around forty years, are primarily intended for children undergoing early puberty (before seven or eight years of age). However, they can also be offered to children who are questioning their gender identity in order to give them time to think. They prevent the secretion of sex hormones (estrogens, testosterone) and slow down or even prevent puberty and its bodily changes (chest, hair, voice, etc.). If treatment is interrupted, puberty resumes its course. Prescriptions for “gender-affirming” hormones (estrogen or testosterone) are also authorized without age conditions with parental authorization. Most often prescribed around the age of 15, they help develop the attributes of one sex or the other. Their impact is partly irreversible (hair, voice) and can reduce fertility. Reassignment surgeries – face, chest and genitals in order to make the body conform to the perceived gender are only accessible from the age of 18. Since a decree of February 8, 2010, transitional care is generally covered by Health Insurance, and even reimbursed 100% if the person has been diagnosed as suffering from a “long-term condition”.
Abroad, some of our neighbors who were until now more liberal than us are starting to backtrack, in favor of a more cautious approach. Many doctors cite a lack of evidence on the benefits for young people and the potential long-term effects of treatments, while noting an increase in the number of young people questioning their gender identity.
Access restrictions
The United Kingdom illustrates this case particularly well, since it has decided to ban puberty blockers for under-18s last December, confirming a temporary ban issued earlier in the year. Children and adolescents who have questions about their gender will therefore no longer be able to benefit from puberty inhibitors. Denmark has also decided to restrict access to these therapies. While the number of consultations at the country’s only specialized clinic for adolescents tripled between 2016 and 2022, from 97 to 352, doctors offer fewer and fewer hormonal treatments (67% of requests were satisfied in 2016 compared to 10% in 2022). Finland has also hardened its position and chosen to favor psychological support and only authorize hormonal treatments for adolescents whose gender identity is considered “permanent”. In Norway, the government agency Ukom published new recommendations in March 2024 aimed at limiting puberty blockers and surgeries to clinical trials.
Sweden, the first country to legalize gender transition in 1972, has also seen a sharp increase in the number of people suffering from gender dysphoria, the distress linked to an incongruence between an individual’s gender identity and the sex assigned to them. birth. Between 2007 and 2017, the number of girls aged 13 to 17 treated for this disorder increased from 31 to 727. In 2021, Karolinska University Hospital in Stockholm decided to ban the use of hormone blockers. A year later, the authorities estimated that the risks “probably outweighed the benefits”, henceforth limiting the use of blockers to “exceptional” cases. But in 2024, the Swedish parliament passed a law that lowers the age at which a person can change their legal sex from 18 to 16, and makes the procedure easier. Removal of the ovaries or testicles is only authorized from the age of 23.
In Australia, the Queensland state government announced in early January its intention to restrict access to puberty blockers for minors. In the United States, before Donald Trump’s declarations, twenty-six states had already passed laws prohibiting gender-affirming care for transgender children and adolescents, or prohibiting the use of public funds to provide it. The U.S. Supreme Court, currently dominated by conservative Republican justices, has been tasked with deciding a dispute over one of those laws in Tennessee, which could have a major impact for the other 25 states. Eleven other American states as well as the city of Washington DC have, on the other hand, strengthened the rights of trans people and facilitated their access to care. It remains to be seen whether the decisions of the new American president will have an impact on these policies.
Some European countries, however, continue to enact laws facilitating procedures or care for trans people. Spain, for example, legalized sex change at the civil registry from the age of 16 in 2023, although the law raises always controversies. This new law also makes it possible to extend gender self-determination to 12-16 year olds (12-14 year olds must obtain the green light from the courts, 14-16 year olds only need the agreement of their guardians legal). In October 2024, Germany passed a similar law allowing you to change your gender through a simple declaration to the civil registry. For those under 14, only parents or guardians will be able to initiate proceedings. Minors over the age of 14 will be able to do so themselves, but only with the consent of their parents.
Return of more conservative values
The general trend nevertheless remains towards restrictions. How to explain this phenomenon? Part of the answer lies in the return of more conservative values in many countries, but also in concern about the increase in the number of cases among young people. But another part of the explanation lies in the scientific field. Until now, many clinics and doctors relied on the “Dutch protocol”, considered the gold standard for care for transgender children. The latter was set up more than 20 years ago to treat young people with gender dysphoria. It was enhanced with scientific studies, including one published in 2011 involving a group of 70 adolescents showing that puberty blockers, combined with therapy, improve the psychological functioning of children. The second, published in 2014 and following 55 patients for seven years, suggests that access to these treatments improved patients’ mental health and reduced their gender dysphoria.
But in recent years, researchers have called these results into question, recalling that the profile of young trans people has evolved significantly or that the first studies did not follow the evolution of patients long enough into adulthood. In 2015, Finnish researchers thus published a study showing that their female patients were “significantly over-represented” in two gender identity clinics, contrary to Dutch studies, which could suggest different needs. This work also shows that unlike the participants in the Dutch studies, many of these new patients did not experience gender-related disorders before puberty and suffered from other mental disorders, including depression and autism.
The well-documented prevalence of mental illness among trans children is poorly understood. For example, it remains difficult to determine to what extent these mental disorders are linked to the numerous discriminations of which they are victims or whether they pre-exist the transition requests. In France, the Academy of Medicine, one of the rare authorities to have spoken on this subject, believes that “great medical caution must be exercised in children and adolescents, given the vulnerability, in particularly psychological, of this population and the numerous undesirable effects, even serious complications, that some of the available therapies can cause. The side effects, which are poorly understood, concern growth, fertility, and psychological and emotional consequences.
But the most elaborate critique was produced by Dr Hilary Cass, the former president of the UK’s Royal College of Paediatrics and Child Health charged with reviewing the evidence on medical care for transgender young people. Its 338-page report published in April 2024 concludes that the evidence for the effectiveness of puberty blockers in reducing gender dysphoria and improving the mental health of transgender children is weak. The analysis highlights a lack of knowledge on the long-term effect of cognitive and psychosexual development. On the other hand, the report finds no clear explanation for the increase in the number of children and adolescents suffering from gender dysphoria.
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