gender reassignment surgery switzerland

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26.10.2023 - New statistical information

Gender reassignment surgery in Swiss hospitals 2019-2022

In 2022, 486 people were admitted to hospital to carry out one or more gender affirmation operations. In 68% of cases, the aim of the surgery was to change the gender of the person from female to male, in 32% of cases from male to female. In Switzerland, almost all gender transition surgery is carried out in five hospitals. 

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European Countries Restrict Trans Health Care for Minors

Citing insufficient research, European health bodies from Sweden to France are taking a more conservative approach to gender-affirming care for minors.

Europe Cools on Trans Care for Minors

Vuk Valcic | SOPA Images | Getty Images

Protesters hold 'Trans rights now' placards and a transgender pride flag during a demonstration in London on Jan. 21, 2023. The United Kingdom is among several countries in Europe that are rethinking minors' access to gender-affirming care.

Chase, a transgender teenager who identifies as non-binary, has been trying to access gender-affirming health care in the United Kingdom since the age of 13. Three years later, the wait continues.

Chase has been officially on a waitlist for care within the National Health Service system for more than a year due to high demand and, more recently, operational delays. The 16-year-old, who uses the pronoun they, says the long wait has been harmful to their mental health and, about six months ago, decided to turn to private hormone therapy treatment.

Due to an ongoing independent review of gender identity services for youth in the U.K. commissioned by its public health authority, minors like Chase might be waiting a while for clarity. Theresa, Chase’s mother, notes that because of the uncertainty around possible care-related policy changes, their situation can feel like “death by a thousand cuts.” (U.S. News is not using the real names of Chase or Theresa to protect their privacy.)

“It's infuriating really,” Chase adds.

The U.K. is not the only European country that is rethinking how to approach gender-affirming care for minors. Several countries, including traditionally more progressive nations like Sweden and Norway , are changing guidelines at least in part due to questions from some doctors about the risks of such procedures. The changes in Europe are occurring more often at the health care policy level initiated by medical professionals, rather than through new or adjusted laws pushed by legislators, and experts say they haven’t been politicized to the extent they have been in the U.S.

“This is not a legal battle in Europe,” says Cianán Russell, a senior policy officer at ILGA-Europe, the European arm of the International Lesbian, Gay, Bisexual, Trans and Intersex Association. Rather, “governments are changing guidelines or instructions to different institutions, or the institutions are changing their policies themselves.”

The Human Rights Campaign, an LGBTQ+ advocacy group based in the U.S., defines gender-affirming care as “age-appropriate care that is medically necessary for the well-being of many transgender and non-binary people who experience symptoms of gender dysphoria, or distress that results from having one’s gender identity not match their sex assigned at birth.” Care can come in a variety of ways, from mental health support to hormone treatment like what Chase is using, to, in some cases, surgical procedures. Advocates say holistic support, or a combination of mental and medical treatments – which is recommended in the World Professional Association for Transgender Health’s standards of care – is generally the best approach.

In the U.S., conservatives often oppose the concept of youth gender-affirming due to religious beliefs and concerns about child abuse. However, in Europe the reluctance appears to be more based on science than politics, with some medical professionals questioning the health risks of administering transitional treatments on minors. One 2022 report commissioned by the Swedish government, for example, concluded that the “scientific basis is not sufficient” to continue to conduct hormone treatments on children without further research.

“Health care should not provide interventions that we do not know to be safe and beneficial,” Mikael Landén, a professor and chief physician at the University of Gothenburg in Sweden and co-author of the report, wrote in an email. “From the lack of evidence follows that a conservative approach is warranted.”

But the broader picture in Europe is not all negative from the perspective of those in favor of trans rights, Russell says, and there are plenty of examples of trends viewed positively by advocates. They say that more than 60% of the total population of the European Union – including countries such as Belgium , Germany , Italy and the Netherlands – have “clear policies in place about offering transition-related care to minors,” such as puberty blockers and hormone treatments. Additionally, the recently updated trans rights map published by Transgender Europe – a nonprofit that promotes the full equality and inclusion of all trans people on the continent – finds that 25 of the 27 E.U. member states provide legal gender recognition procedures.

A more detailed picture given by the organization brings advocates some cause for worry, however. Of the 25 E.U. members that offer those procedures, four demand sterilization, only one offers full non-binary recognition and less than half (12) offer legal gender recognition procedures for minors.

In recent years, at least a handful of European countries have gently tapped the breaks on gender-affirming care for minors.

In Finland , specialized adolescent psychiatric gender identity teams have been available for minors at two university hospitals since 2011 through the country’s adoption of the so-called “ Dutch approach ,” which in part holds that adolescents experiencing gender dysphoria “can be considered eligible for puberty suppression and subsequent cross-sex hormones when they reach the age of 16.” But after years of additional research, a public health body in Finland recommended that minors experiencing gender dysphoria first be provided with psychological support and, if further medical treatment is pursued, that the patient be made “aware of the risks associated with them.”

In 2022, the Swedish government’s National Board of Health and Welfare said hormone treatments for minors “should be provided within a research context” and offered “only in exceptional cases,” while adding that the “risks of puberty suppressing treatment … and gender-affirming hormonal treatment currently outweigh the possible benefits.”

In Norway, the country’s Healthcare Investigation Board recommended in part that gender-affirming care treatments such as puberty blockers be defined as experimental. Meanwhile in France , the Académie Nationale de Médecine in February 2022 recommended the “greatest reserve” when considering puberty blockers or hormone treatments due to possible side effects such as “impact on growth, bone weakening, risk of infertility” and others, according to a translation.

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Marci Bowers, the president of the World Professional Association for Transgender Health, says the situation around youth gender-affirming care in some European countries is indeed different than in America – but she has confidence in the direction that ongoing research is headed.

“(European countries) are trying to be objective,” Bowers says. “Although they are forcing patients to become research subjects, basically, as a condition of their care, the good news is that they fund that research.”

Questions about treatment will be answered, she adds, and “they're probably going to be answered affirmatively.”

Russell, of ILGA-Europe, believes the questions around health care for transgender youth on the continent are coming from a “small minority,” but that the “vast majority of doctors who work with trans people day-in and day-out support the kind of care” promoted by the World Professional Association of Transgender Health’s standards of care. They also reference the World Health Organization’s latest International Classification of Diseases, which describes gender incongruence as a sexual – not mental – health condition.

If there is a consensus, it hasn’t been reflected in Chase’s experience.

In late 2022, Reuters reported that England’s National Health Service – as part of its review of gender-affirming care for minors – was considering calling for local authorities to be alerted about cases in which families pursue private care for their transgender children outside of the public system. Chase’s family was one of those that had pursued private options, though they were unaware of the potential consequences.

Courtesy of the family

Chase and their mom Theresa visit Whitby Abbey in England.

Theresa says they were referred to social services, but that the case was eventually resolved when Chase’s general practitioner assured a representative that Chase was “ competent to make their own decisions about their health care” and not being pressured to access private testosterone treatment by their parents.

Almost two years after the review was launched, the NHS last summer announced that it would be decommissioning the Gender Identity Development Service, or GIDS – England’s only clinic geared toward youth with gender dysphoria – and transitioning its services to two regional hubs. The latter piece of the news was largely applauded by advocates. The changes came after the independent review commissioned by the NHS found, in part, a “lack of clinical consensus and polarized opinion on what the best model of care for children and young people experiencing gender incongruence and dysphoria should be” in the country.

But activists have still expressed concern over GIDS’ already long waitlist coupled with delayed openings for the regional locations, along with the fact that no new appointments will be scheduled until one hub opens in late 2023. Bowers notes the difficulty for these children that can come with waiting, adding that the effects of puberty can be “pretty depressing” for some with the angst they are already experiencing.

In the meantime, leaked draft guidelines make the situation even more cloudy. The NHS recently announced an interim policy holding that “puberty-suppressing hormones should not be routinely commissioned for children and adolescents” outside of research settings, citing the “significant uncertainties” surrounding the use of hormone treatments.

The ongoing review’s final report – and, thus, official guidance for how youth gender-affirming care should move forward – is set to be released later this year.

“I talk to young people all the time,” says Kai O’Doherty, the head of policy and research at Mermaids, a nonprofit organization based in the U.K. that supports trans youth. “It seems like they're completely absent from, actually, the conversation of what they need and what they're gonna get.”

Deekshitha Ganesan, a policy officer focused on health at Transgender Europe, says something that’s often forgotten in the recent debate about access to gender-affirming health care is that trans people’s quality of life and, as a result, ability to participate in society, “has improved so greatly” by having that access to such care.

For now, however, transgender minors across several European countries will continue to face uncertainty.

“I'm lucky in that I have a really good support system and stuff like that, but occasionally I think, ‘Things are getting worse. I'm getting older,’” Chase says. “Honestly, the thing I think is best for me at the minute is to go somewhere else. Like I honestly don't know what would happen if I stayed here, you know what I mean? But then it's like, where would you go? Because it's the same in America. It’s the same in a whole lot of places.”

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Swiss to allow simple legal gender transition from Jan. 1

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Right to change legal gender

You can change your legal gender in 67 countries, but 35 require surgery..

Legal recognition of sex reassignment by permitting a change of legal gender on an individual's birth certificate.

Timeline of right to change legal gender

Recent & upcoming changes, upcoming changes.

• Czech Republic Legal, but requires medical diagnosis July 1
• Sweden Legal, no restrictions July 1
• Germany Legal, no restrictions November 1
• Idaho Illegal July 1
• Iraq Illegal April 27
• Florida Illegal January 30
• Pakistan Legal, no restrictions December 13
• Montana Illegal October 23
• Russia Illegal July 24
• Chechnya Illegal July 19
• Illegal July 19
• Kansas Illegal July 1
• Tennessee Illegal July 1
• New Zealand Legal, no restrictions June 15
• Pakistan Illegal May 19
• Finland Legal, no restrictions April 3
• Slovakia Legal, but requires medical diagnosis March 3
• Bulgaria Illegal February 21
• Andorra Legal, no restrictions February 17
• Hong Kong Legal, no restrictions February 6
• Spain Legal, no restrictions December 22
• Queensland Legal, no restrictions December 2
• Cyprus Legal, no restrictions November 23
• Montana Legal, no restrictions September 19
• North Carolina Legal, no restrictions June 23
• Montana Illegal May 23
• Japan Legal, but requires surgery April 1
• Lithuania Legal, but requires medical diagnosis February 2
• Oklahoma Illegal February 1
• Suriname Illegal January 1
• Switzerland Legal, no restrictions January 1

Right to change legal gender by Country

Legal, no restrictions.

Right to change legal gender is legal, no restrictions in 32 regions.

• Bangladesh 2013
• Pakistan 2023
• Taiwan 2021
• Europe (16)
• Andorra 2023
• Belgium 2018
• Croatia 2014
• Cyprus 2022
• Denmark 2014
• Finland 2023
• France 2018
• Greece 2017
• Iceland 2019
• Ireland 2015
• Luxembourg 2018
• Norway 2016
• Portugal 2018
• Switzerland 2022
• North America (3)
• Canada 2017
• Costa Rica 2018
• Mexico 2009
• Botswana 2017
• Mozambique 2004
• Oceania (1)
• New Zealand 2023
• South America (7)
• Argentina 2012
• Bolivia 2016
• Brazil 2018
• Colombia 2015
• Ecuador 2016
• Uruguay 2018

Legal, but requires medical diagnosis

Right to change legal gender is legal, but requires medical diagnosis in 22 regions.

• Israel 2014
• Sri Lanka 2016
• Uzbekistan 1998
• Europe (15)
• Austria 2009
• Belarus 2010
• Estonia 1999
• Germany 2011
• Lithuania 2022
• Netherlands 2013
• Poland 1995
• Serbia 2019
• Slovakia 2023
• Slovenia 2005
• Sweden 2013
• Ukraine 2016
• United Kingdom 2005
• Angola 2015
• South Africa 2004
• South America (1)

Legal, but requires surgery

Right to change legal gender is legal, but requires surgery in 35 regions.

• Indonesia 1973
• Kazakhstan 2011
• Kyrgyzstan 2020
• Lebanon 2016
• Mongolia 2009
• Singapore 1996
• South Korea
• Turkmenistan 1972
• Vietnam 2017
• Europe (12)
• Albania 2009
• Armenia 1972
• Azerbaijan 1972
• Bosnia and Herzegovina
• Czech Republic 1975
• Georgia 2008
• Kosovo 1989
• Latvia 2012
• North Macedonia 2019
• Romania 1996
• Turkey 2017
• North America (2)
• Panama 1972
• Tunisia 2018
• Zimbabwe 1986

Right to change legal gender is illegal in 97 regions.

• Afghanistan
• Bahrain 2014
• Malaysia 1983
• Philippines 2007
• Saudi Arabia
• Timor-Leste
• United Arab Emirates 2019
• Bulgaria 2023
• Hungary 2020
• Liechtenstein 2016
• Russia 2023
• Vatican City
• North America (17)
• Antigua and Barbuda
• Dominican Republic
• El Salvador 2017
• Saint Kitts and Nevis
• Saint Lucia
• Saint Vincent and the Grenadines
• Trinidad and Tobago
• Africa (41)
• Burkina Faso
• Central African Republic
• Côte d’Ivoire
• Democratic Republic of the Congo
• Equatorial Guinea
• Guinea-Bissau
• Republic of the Congo
• Sao Tome and Principe
• Sierra Leone
• South Sudan
• Oceania (11)
• Federated States of Micronesia
• Marshall Islands
• Papua New Guinea
• Solomon Islands
• South America (4)
• Suriname 2022

No data, no laws, N/A, or ambiguous

Data on right to change legal gender is unclear, not applicable, or missing in 11 regions.

• North Korea
• North America (1)
• United States
• Oceania (2)
• Antarctica (1)

Spot an error? Visit the region and select "Accurate?: No" so Equaldex's editors can review it.

Switzerland To Allow Simple Legal Gender Transition From January 1

Switzerland joins Ireland, Belgium, Portugal and Norway as one of the few countries on the continent that allow a person to legally change gender without hormone therapy, medical diagnosis or further evaluation or bureaucratic steps.

Younger people and those under adult protection will require guardian consent.

People in Switzerland will be able to legally change gender by a visit to the civil registry office from Jan. 1, putting the country at the forefront of Europe's gender self-identification movement.

Under the new rules written into Switzerland's civil code, anyone aged 16 and above who is not under legal guardianship will be able to adjust their gender and legal name by self-declaration at the civil registry office. Younger people and those under adult protection will require guardian consent.

This marks a change from the current set of regionally prescribed standards in Switzerland, which often require a certificate from a medical professional confirming an individual's transgender identity.

Some cantons - semi-autonomous regions in federal Switzerland - also require a person to undergo hormone treatment or anatomical transition in order to legally change gender, while, for a name change, proof could be required that the new name has already been unofficially in use for several years.

Switzerland, long known as socially conservative in the main, voted in September to legalise civil marriage and the right to adopt children for same-sex couples, one of the last countries in Western Europe to do so.

With the new gender change rules, Switzerland joins just two dozen countries worldwide aiming to decouple gender choice from medical procedures.

While some other European nations including Denmark, Greece and France have removed the requirement of medical procedures, including sex reassignment surgery, sterilisation or psychiatric evaluation, their rules require further steps or conditions.

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Spain in June approved a draft bill allowing anyone over the age of 14 to change gender legally without a medical diagnosis or hormone therapy. Germany in 2018 became the first European government to introduce a third gender option but in June 2021 shot down two bills aiming to introduce gender self-identification. A new transgender member of parliament is hoping to address that.

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A team approach to the indication for gender reassignment surgery in transsexuals resulting in long-term outcome improvement

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At the University of Basel (Switzerland), a multidisciplinary team was established for pre-operative selection and treatment of patients with gender dysphoria. As a result, the indications for surgical gender reassignment could be judged with considerably greater accuracy than previously possible. In the 9-year period of this prospective study only 14 of 57 patients with gender dysphoria were selected for surgical treatment. At the time of this survey, six patients are still under psychiatric preoperative evaluation, and six further male-to-female transsexuals are under hormonal treatment awaiting surgery. Following the operation, only one of nine male-to-female patients is socially unstable and that patient’s quality of life is worse than prior to gender reassignment. Of the female-to-male transsexuals, all four are stable in their professional and family relations. In conclusion, a comprehensive evaluation of patients with gender dysphoria and the conclusive indications established within the team considerably improved the postoperative outcome of gender reassignment.

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de Roche, R., Rauchfleisch, U., Noelpp, B. et al. A team approach to the indication for gender reassignment surgery in transsexuals resulting in long-term outcome improvement. Eur J Plast Surg 27 , 24–28 (2004). https://doi.org/10.1007/s00238-004-0596-z

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Age restriction lifted for gender-affirming surgery in new international guidelines

'Will result in the need for parental consent before doctors would likely perform surgeries'

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• Release Date: September 16, 2022

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Kristin Samuelson

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• Expert can speak to transgender peoples’ right to bodily autonomy, how guidelines affect insurance coverage, how the U.S. gender regulations compare to other countries, more

CHICAGO --- The World Professional Association for Transgender Health (WPATH) today today announced  its updated Standards of Care and Ethical Guidelines for health professionals. Among the updates is a new suggestion to lift the age restriction for youth seeking gender-affirming surgical treatment, in comparison to previous suggestion of surgery at 17 or older. 

Alithia Zamantakis (she/her), a member of the Institute of Sexual & Gender Minority Health at Northwestern University Feinberg School of Medicine, is available to speak to media about the new guidelines. Contact Kristin Samuelson at [email protected] to schedule an interview.

“Lifting the age restriction will greatly increase access to care for transgender adolescents, but will also result in the need for parental consent for surgeries before doctors would likely perform them,” said Zamantakis, a postdoctoral fellow at Northwestern, who has researched trans youth and resilience. “Additionally, changes in age restriction are not likely to change much in practice in states like Alabama, Arkansas, Texas and Arizona, where gender-affirming care for youth is currently banned.”

Zamantakis also can speak about transgender peoples’ right to bodily autonomy, how guidelines affect insurance coverage and how U.S. gender regulations compare to other countries.

Guidelines are thorough but WPATH ‘still has work to do’

“The systematic reviews conducted as part of the development of the standards of care are fantastic syntheses of the literature on gender-affirming care that should inform doctors' work,” Zamantakis said. “They are used by numerous providers and insurance companies to determine who gets access to care and who does not.

“However, WPATH still has work to do to ensure its standards of care are representative of the needs and experiences of all non-cisgender people and that the standards of care are used to ensure that individuals receive adequate care rather than to gatekeep who gets access to care. WPATH largely has been run by white and/or cisgender individuals. It has only had three transgender presidents thus far, with Marci Bower soon to be the second trans woman president.

“Future iterations of the standards of care must include more stakeholders per committee, greater representation of transgender experts and stakeholders of color, and greater representation of experts and stakeholders outside the U.S.”

Transgender individuals’ right to bodily autonomy

“WPATH does not recommend prior hormone replacement therapy or ‘presenting’ as one's gender for a certain period of time for surgery for nonbinary people, yet it still does for transgender women and men,” Zamantakis said. “The reality is that neither should be requirements for accessing care for people of any gender.

“The recommendation of requiring documentation of persistent gender incongruence is meant to prevent regret. However, it's important to ask who ultimately has the authority to determine whether individuals have the right to make decisions about their bodily autonomy that they may or may not regret? Cisgender women undergo breast augmentation regularly, which is not an entirely reversible procedure, yet they are not required to have proof of documented incongruence. It is assumed that if they regret the surgery, they will learn to cope with the regret or will have an additional surgery. Transgender individuals also deserve the right to bodily autonomy and ultimately to regret the decisions they make if they later do not align with how they experience themselves.” 

A Teen Gender-Care Debate Is Spreading Across Europe

Doubts have now come to the Netherlands, where the most-contested interventions for children and adolescents were developed.

As Republicans across the U.S. intensify their efforts to legislate against transgender rights, they are finding aid and comfort in an unlikely place: Western Europe, where governments and medical authorities in at least five countries that once led the way on gender-affirming treatments for children and adolescents are now reversing course, arguing that the science undergirding these treatments is unproven, and their benefits unclear.

The about-face by these countries concerns the so-called Dutch protocol, which has for at least a decade been viewed by many clinicians as the gold-standard approach to care for children and teenagers with gender dysphoria. Kids on the protocol are given medical and mental-health assessments; some go on to take medicines that block their natural puberty and, when they’re older, receive cross-sex hormones and eventually surgery. But in Finland, Sweden, France, Norway, and the U.K., scientists and public-health officials are warning that, for some young people, these interventions may do more harm than good.

European health authorities are not reversing themselves on broader issues of trans rights, particularly for adults. But this turn against the Dutch protocol has inflamed activists and politicians in the United States. Republicans who have worked to ban its recommended treatments claim that the shifts in Europe prove they’re right. Their opponents argue that any doubts at all about the protocol, raised in any country whatsoever, are simply out of step with settled science: They point to broad endorsements by the American Medical Association, the American Psychiatric Association, and the American Academy of Pediatrics, among other groups; and they assert that when it comes to the lifesaving nature of gender-affirming care, “ doctors agree .”

But doctors do not agree, particularly in Europe, where no treatments have been banned but a genuine debate is unfurling in this field. In Finland, for example, new treatment guidelines put out in 2020 advised against the use of puberty-blocking drugs and other medical interventions as a first line of care for teens with adolescent-onset dysphoria . Sweden’s National Board of Health and Welfare followed suit in 2022, announcing that such treatments should be given only under exceptional circumstances or in a research context. Shortly after that, the National Academy of Medicine in France recommended la plus grande réserve in the use of puberty blockers. Just last month, a national investigatory board in Norway expressed concerns about the treatment. And the U.K.’s only national gender clinic for children, the Tavistock, has been ordered to close its doors after a government-commissioned report found, among other problems, that its Dutch-protocol-based approach to treatment lacked sufficient evidence.

These changes in Europe have so far been fairly localized: Health authorities in many countries on the continent—among them Austria, Denmark, Germany, Italy, and Spain—have neither subjected the Dutch approach to formal scrutiny nor advised against its use. Yet questions about the protocol seem to be spreading. At the end of March, for example, a Belgian TV report described a 42-fold increase in patients at a leading gender clinic in Ghent and raised questions about the right approach to care. Doubts about the protocol have even come to the country that invented it, at the Center of Expertise on Gender Dysphoria in Amsterdam. “Until I began noticing the developments in other EU countries and started reading the scientific literature myself, I too thought that the Dutch gender care was very careful and evidence-based,” Jilles Smids, a postdoctoral researcher in medical ethics at Erasmus University in the Netherlands, told me via email. “But now I don’t think that any more.”

Kirsten Visser, a Netherlands-based advocate and consultant for parents of trans teens, says her own son, Sietse, started receiving “definitely lifesaving” care at the Amsterdam center in 2012, at the age of 11. Around the time that Sietse showed up at the clinic, the Dutch protocol was becoming established internationally, largely through the work of a child and adolescent psychiatrist there named Annelou de Vries.

After completing a Ph.D. on gender dysphoria in Dutch adolescents, de Vries published two seminal papers with the clinical psychologist Peggy Cohen-Kettenis and other colleagues, in 2011 and 2014. The former looked at the psychological effects of puberty suppression on 70 young people over a period of two years, on average; the latter tracked outcomes for 55 of those people who had gone on to receive gender-reassignment surgery, over an average of six years. Taken together, the studies found that the teens showed fewer symptoms of depression after having their puberty suppressed, as well as a decrease in behavioral and emotional problems; and that the ones who went on to take gender-affirming hormones and have surgery grew into “well-functioning young adults.” De Vries’s expertise has since been widely recognized within the field: She served as a co-lead on the revision of the adolescent section of care guidelines recently published by the World Professional Association for Transgender Health, and is now president-elect of the European equivalent, EPATH.

But in the years after her two studies were released, research done in other European countries led to concerns about their relevance. In 2015, for example, Finnish researchers described a phenomenon that “ called for clinical attention ,” as they put it: More children were reporting gender dysphoria, and a greater proportion of them had been assigned female at birth. The fact that three-quarters of those Finnish teens had been diagnosed with separate and severe psychiatric conditions appeared to be at odds with the data from the Netherlands, the paper argued. The Dutch studies had found that just one-third of adolescents with gender dysphoria experienced other psychiatric issues, suggesting they were in far better mental health.

In Sweden, too, clinicians grew alarmed by the sudden increase in the number of teenagers seeking gender care. Mikael Landén, a professor of psychiatry at the University of Gothenburg, told me that this population has increased 17-fold since 2010. One explanation for that change—that more open-minded attitudes around gender have emboldened kids to seek the help they need—just doesn’t ring true to him. He’d studied those views in his early work, he said, and found that, on the whole, Swedish attitudes toward transgender people have been very positive for a long time.

When the government asked Landén and a group of other scientists to write an evidence-based review of hormone-based treatments for young people, their verdict, after two years of study, was expressed definitively: The original research findings from de Vries were outdated, and do not necessarily apply to the group of teens who have been coming forward in more recent years. The Dutch protocol had been “a valuable contribution,” he told me, and “it was reasonable to start using it” in Sweden. But times had changed, and so had the research literature. In 2021, for instance, a team based at the U.K.’s Tavistock clinic published research showing no detectable improvements in the mental health of youngsters who had been put on puberty blockers and followed for up to three years.

Read: The war on trans kids is totally unconstitutional

De Vries acknowledged some concerns about the research when we spoke in February. “Our early outcomes studies were really from another time and comprised small samples,” she told me, and they looked only at trans youth who had experienced gender dysphoria from childhood. She granted that there is some research to suggest that kids who don’t arrive at the clinic until they’re older are worse off, psychologically, than their younger peers; but she also said her team has run studies including 16-year-olds, and that their findings were “not worrisome.” She agrees that other researchers have not replicated the long-term follow-up research on kids who went through the Dutch protocol, but she pointed out that the short-term benefits of such treatment have indeed been seen in other studies. Research conducted in the U.S., and published earlier this year, found that a group of 315 trans and nonbinary youth were on average less depressed and anxious , and better-functioning, after two years of hormonal treatment.

In the meantime, de Vries and her colleagues have urged clinicians in other countries to do more of their own investigation, in part because the youngsters who receive care at gender clinics in the Netherlands seem to be in comparatively good mental health from the get-go. It’s not yet clear, she told me, that studies of this group will be applicable to youth in other countries. “Every doctor or psychologist who is involved in transgender care should feel the obligation to do a good pre- and post-test,” one of de Vries’s co-authors on the 2011 and 2014 studies said to a Dutch newspaper in 2021. “The rest of the world is blindly adopting our research.”

De Vries is now working on a research project, funded by an $864,000 grant, that will try to answer newly forming doubts about the Dutch protocol. Her proposal for the grant, filed in 2021, described its subject as a “once so welcomed but now sharp[ly] criticized approach.”

That such criticisms are becoming mainstream even in her own country is itself a startling development. After all, the Netherlands has long been at the vanguard of progressive health-care practices. When the Dutch approach to transgender care for adults first started taking shape during the 1970s (many years before the protocol for kids would be established), the country’s politics were dominated by a steadfast opposition to taboos. James Kennedy, an American-born professor of modern Dutch history at Utrecht University, has described this as the country’s “compassionate culture”: In a radical departure from its traditional Christian conservatism, long-standing policies were being spurned; and even touchy subjects such as death and sex were made the subject of broad public-policy debates. Sex work, for example, was widely tolerated , then legalized in 2000. Similarly, the Royal Dutch Medical Association offered formal guidelines for the practice of euthanasia in the 1980s, and a corresponding national law—one of the world’s first—codified the rules in 2002.

Against this backdrop of openness, in which doctors were seen as authoritative figures who were well equipped to decide what was best for their patients, one of the first dedicated clinics for transgender people was established in Amsterdam in 1972. It offered an array of services—blood tests, hormone therapy, and surgeries—to trans adults. According to a recent book by the historian Alex Bakker, Dutch surgeons, some of them inspired by their Christian beliefs, developed techniques that would reduce patients’ psychological suffering. “Helping those in need trumped ‘taboos’ about the sanctity of life or fixed gender roles,” Kennedy told me. The Dutch protocol for treating gender dysphoria in children, as established in the 1990s, reflected a further extension of this philosophy, aiming to smooth adult transitions by intervening early.

Read: Take detransitioners seriously

Nevertheless, in December, a journalist named Jan Kuitenbrouwer and a sociologist named Peter Vasterman published an opinion piece in a leading daily newspaper, NRC , that took aim at the Dutch protocol and its “shaky” scientific foundations, and alluded to the international scrutiny of the past few years. “It is remarkable that the media in our neighboring countries report extensively on this reconsideration,” the article said, “but the Dutch hardly ever do.” Like critics elsewhere, Kuitenbrouwer and Vasterman pointed to the rising numbers of children seeking care, from 60 to 1,600 in the Netherlands across a dozen years, and the unaccounted rise in those assigned female at birth; and they suggested that this new generation of people seeking treatment is not analogous to those included in the studies conducted by de Vries a decade ago. De Vries and some colleagues countered that their more recent research addresses this concern. “Scientific evaluation has always been an integral part of this challenging model of care, where young people make early decisions about medical interventions with lifelong implications,” they wrote in the same newspaper.

Also in December, a clinical psychologist at Radboud University’s gender clinic in Nijmegen named Chris Verhaak told a different Dutch outlet that puberty blockers affect children’s bones, and maybe also their brain development. “It is not nothing,” she said. Verhaak is currently running a government-funded study to understand the source and nature of the increase in the number of patients. (Results are due to be presented to the Dutch House of Representatives this year.) In another interview that month, she said that for up to half of cases, the gains in suppressing puberty are not clear. “I worry about that,” she told the newsweekly De Groene Amsterdammer . “Especially because we also experience enormous pressure to provide these puberty inhibitors as quickly as possible.”

Verhaak’s comments in particular sparked dismay among trans groups, which saw them as promoting destructive narratives about social contagion. Verhaak and her direct collaborators say that they are no longer speaking to the media until their study is released, but Hedi Claahsen, a professor and principal clinician on the Radboud center’s gender team, told me that practitioners are cautious and follow national guidelines. When I asked if her center’s approach differed from the one used in Amsterdam, she told me, “No clinic is exactly the same.” Individual providers, who are working at different institutions, may end up providing care that reflects “a different vision.”

Another, more significant round of criticism arrived at the end of February, when another widely read Dutch newspaper, de Volkskrant , published a 5,000-word article under a headline reading: “The treatment of transgender youth in the Netherlands was praised. Now the criticism of ‘the Dutch approach’ is growing.” The authors spoke with Iris, a 22-year-old woman who spent five years on testosterone and had a double mastectomy that she now regrets; they pointed to a new population of kids assigned female at birth seeking care only in their teens; and they noted reservations about the protocol in Finland and Sweden. “Is the ‘Dutch approach’ still the way to go?” the story asked.

The article prompted debate on Twitter, where Michiel Verkoulen, a health economist working with the government of the Netherlands to address the long-standing problem of ever-expanding waiting lists and their impact on young people’s mental health, accused the Dutch protocol’s critics of ignoring what he described as the elephant in the room. “What to do with the people for whom transgender care is critical?” he asked. “You can put every research aside, keep asking for more, and argue that diagnostics and treatments should be stricter … But the question remains: W hat then ?”

“In the Netherlands there are more and more people saying that gender diversity is woke and it’s nonsense and it’s bullshit,” Visser, the consultant for parents of trans teens, told me. Sam van den Berg, a spokesperson for an Utrecht-based trans-rights organization called Transvisie, argued that this debate does not need to happen. The quality of care for children with gender dysphoria is better in the Netherlands than almost anywhere else, she said. “We don’t feel it’s necessary to change anything.” Indeed, doctors in the Netherlands are still free to provide gender-affirming care as they see fit. The same is true of their colleagues in Finland, Sweden, France, Norway, and the U.K., where new official guidelines and recommendations are not binding. No legal prohibitions have been put in place in Europe, as they have been in more than a dozen U.S. states, where physicians risk losing their medical license or facing criminal sanctions for prescribing certain forms of gender-affirming care.

But the trend toward more conservative application of the Dutch protocol is likely to have real effects in European countries, in terms of which kids get treatment, and of what kind. Louise Frisén, an associate professor at Karolinska Institute and a pediatric psychiatrist at the child and adolescent mental-health clinic in Stockholm, Sweden, told me she worries that under her country’s new guidelines, many of her teenage patients will find it harder to access medical care. The benefits of treatment are clear, she said, and she further claimed that the policy change has caused anguish for some patients who are panicking at the looming prospect of puberty.

As for de Vries, when I spoke with her a few weeks before the article in de Volkskrant was published, she agreed that clinicians should be cautious, but not to the point where treatment becomes inaccessible. Outcomes for those with later-onset dysphoria do need to be investigated further, she acknowledged, but “if we are going to wait ’til the highest-standard medical evidence provides us the answers, we will have to stop altogether.” In that sense, Europe’s brewing disagreement over treatment could turn into paralysis. “That’s what worries me,” she said. “You will always have to work with uncertainties in this field.”

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European Countries’ Restrictions on Gender Treatment for Minors Contrast Sharply With US Push

Citing serious health risks and a lack of supporting evidence, Sweden, France and England have all adopted a more critical stance toward ‘gender-affirming care’ for youth — a stark difference to the approach taken in many U.S. states and cultural institutions.

At both the federal and the state level, and in the American culture more broadly, there is a concerted effort to remove obstacles to minors’ access to controversial “gender-affirming care.” 

California , Minnesota and New York have passed legislation establishing their state as a “trans youth refuge,” while the federal government is challenging the legality of state-level restrictions placed on practices like hormone therapy and “sex-reassignment surgery.” Even an academic journal was pressured into retracting a study on “rapid-onset gender dysphoria” after pushback from activists.

In Europe, however, a trend in the opposite direction is unfolding. Judging that the scientific evidence is lacking, that long-term effects remain unknown and that the benefits are outweighed by the risks, governments and health authorities in at least five countries — several of which pioneered in “gender-affirming” hormonal and surgical treatments for minors — seem to be reexamining their decisions.

What’s more, in a letter published in The Wall Street Journal on July 13, clinicians and researchers from nine countries, mainly European, stepped forward to criticize the recently made statement by the president of the American-based Endocrine Society, according to whom “gender-affirming care improves the well-being of transgender and gender-diverse people.”

‘The Risks Outweigh the Benefits’

Considered by many progressives as model societies, the Nordic countries have long been recognized as frontrunners in the transgender-rights movement. In 1972, Sweden became the world’s first country to provide free hormone therapy and permit individuals to change their legal gender after undergoing “sex-reassignment” surgery. Fifty years later, however, the country made a surprising shift, choosing to head in a substantially different direction.

It all started in the autumn of 2018, when the Swedish government introduced a new proposal aiming to lower the minimum age for gender-reassignment treatments from 18 to 15, eliminate the requirement for parental consent, and permit legal gender changes for children as young as 12.

The proposal was heavily criticized by psychiatrists and labeled as “a big experiment on children.” Sparking a social-media backlash, the proposal was eventually withdrawn. After reviewing the scientific evidence on the subject, the Swedish Agency for Health Technology Assessment (SBU) concluded that there was in fact no evidence for the safety or efficacy of the “gender-affirming” treatments.

“While we have no evidence for the efficacy of the treatments, we have a lot of evidence for big health risks,” Sven Román, a Swedish consultant psychiatrist working in child and adolescent psychiatry who signed The Wall Street Journal letter, told the Register. 

“Almost every prepubescent child who receives hormone therapy will become infertile, and their bone density will be severely affected,” Román said. “For example, one clinic in Stockholm treated a young boy who had transitioned to a girl, receiving hormone therapy from a very early age. After a couple of years, when the boy had decided to detransition, his skeleton was like that of an 80-to-90-year-old man. This is irreversible damage.”

In February 2022, the Swedish National Board of Health and Welfare, known as Socialstyrelsen, changed i ts clinical practice guidelines and regulations with respect to “gender-affirming care” for minors, after having formerly recommended the use of puberty blockers, described as “safe and secure,” since 2015. 

Socialstyrelsen’s new recommendations underlined that the risks involved with hormone therapy outweighed the possible benefits. According to the agency, “the scientific evidence is insufficient” to draw conclusions on the effects of puberty blockers, cross-sex hormones and “gender-affirming” surgeries and announced that such treatments should be given only in a research context or under exceptional circumstances.  

According to Román, hormone therapy has not only been shown to affect individuals physically, but also cognitively and psychologically: The evidence, which indicates risks extending beyond infertility, osteoporosis and blood clots to include delayed or arrested neurological development as well as depression, anxiety and suicidal thoughts, is rapidly growing and undisputable.

“The truth is that we have no idea what the long-term effects of these treatments are,” Román said. “It is all a big experiment.”

“These findings show these ‘therapies’ for what they really are, that is, serious and big medical interventions that can lead to grave and permanent consequences,” Samuelle Falk, a psychiatry resident at North Stockholm Psychiatry and Ph.D. student at Karolinska Institutet in Sweden, told the Register. “It is also an indication that sex-reassignment therapy might not be the right answer after all.”

Gaps in the Evidence

Only three days after Sweden changed its guidelines, the National Academy of Medicine in France issued on Feb. 25, 2022, a press release cautioning medical practitioners about the use of puberty blockers. 

Reminiscent of Karolinska University Hospital’s decision to ban the use of hormone blockers, the National Academy wrote that, “if France allows the use of puberty blockers or cross-sex hormones with parental authorization and no age limitations, the greatest caution is needed in their use, taking into account the side-effects such as the impact on growth, bone weakening, risk of sterility, emotional and intellectual consequences and, for girls, menopause-like symptoms.”

Emphasizing the irreversibility of “gender-affirming” surgeries, the National Academy further warned about the growing number of young individuals wishing to “detransition.”

In addition to the health risks mentioned by Román and the French National Academy of Health, recent European-led studies published in the peer-reviewed American Journal of Psychiatry and the Journal of Clinical Endocrinology and Metabolism have shown there are no psychological benefits to either hormone therapy or “sex-reassignment” surgeries and that the discontinuation rates for hormone treatments are as high as 30%.

In a similar fashion, after concerns that children were too quickly referred to hormone therapy at the Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust, an English government report recognized in October 2022 that there were gaps in the evidence base for the efficacy of hormone therapy and thus insufficient evidence to discern the correct clinical approach and appropriate management of children and adolescents with gender dysphoria. 

Following the report, the nation’s only clinic specializing in pediatric gender medicine received orders to close its doors . Now, puberty blockers are only given to minors “in the context of a formal research protocol” in England.

Besides the renowned Bell v. Tavistock case in which Keira Bell took the Tavistock Clinic to court to argue that she had been unable to give proper consent to puberty blockers as a minor, the Christian Medical Fellowship in England further told the Register that many have also argued that “children with comorbidities — autism, behavioral difficulties, or who had suffered physical or sexual abuse — had those underlying issues sidelined and that the medical pathway inaugurated by puberty blockers was the main ‘treatment route’ for children and young people.” 

This resonates with the experience of Sven Román, who said, “I have worked with many children diagnosed with gender dysphoria, and every child has had at least one additional psychiatric disorder, often several ones. The most common psychiatric condition is autism or other autism-like conditions, which two-thirds of the children are diagnosed with. We need to study these connections more.”

After recognizing “gender-reassignment” treatments for minors as “an experimental practice” since most effects are unknown, Finland’s Council for Choices in Healthcare also reported in 2020 that gender dysphoria did not diminish after hormone therapy; instead, the therapy was accompanied by a range of potential risks, including possible disruptions in bone mineralization.

Concluding that “as far as minors are concerned, there are no medical treatments that can be considered evidence-based,” Finland recommended restricting access to puberty blockers and cross-sex hormones and completely prohibiting surgeries for minors. 

“The Finnish guidelines outline that the first line of intervention must be psychosocial,” Riittakerttu Kaltiala, a professor in neuropsychiatry at Tampere University in Finland who also signed the letter in The Wall Street Journal , told the Register. The treatment of any existing mental disorders must also be prioritized, she added. 

“Europe is on the right track,” the Finnish professor added. “Medical practices have to be based on solid medical evidence, and if such evidence does not exist, that is a reason to be cautious.”

A Contrary Approach in the US

According to a study by the organization “Do No Harm” in January 2023, the United States is the “most permissive country” when it comes to gender-affirming treatments. 

“As in many controversial bioethical issues, the U.S. is often polarized according to party lines,” Legionary Father Michael Baggot, assistant professor of bioethics at the Pontifical Athenaeum Regina Apostolorum in Rome, explained to the Register. “It would be unfortunate for care for people with gender dysphoria to remain just one more partisan issue.”

“This field of medicine is very politicized in the U.S.A.,” Finnish professor Kaltiala concurred, “but medicine has to follow the path of medical evidence, not that of political pressures.” 

The situation is somewhat different in Europe, where countries have been using the Dutch protocol as a reference point since the 1990s. The protocol, developed by the Center of Expertise on Gender Dysphoria in Amsterdam, establishes criteria for pharmacological and surgical interventions based on persistent gender dysphoria, absence of psychiatric conditions and informed consent and emphasizes the importance of psychotherapeutic support.

“Countries like Finland and Sweden have so far been especially cautious in applying the protocol rigorously and have been likewise bold in calling attention to failures to adhere to such standards,” Father Baggot said.

While European countries continue to urge cautious approaches to “gender treatments,” the United States has chosen to prioritize the so-called “affirmative model,” Father Baggot added, a model that, granting patient requests without too many obstacles, appears to align with what he called the absolutizing of bodily autonomy in American bioethics. 

Peter Vankrunkelsven, professor emeritus at the Catholic University of Leuven, who also signed the letter in The Wall Street Journal , likewise commended Sweden and Finland for their cautious approaches. 

With regard to the more permissive approach of the United States, Vankrunkelsven explained to the Register, “I believe that a lot of scientists and politicians, although concerned, are not daring or willing to take a firm position because they fear that they might be labeled as transphobic or discriminating.”

In addition to the lack of scientific evidence for the efficacy and safety of the treatments involved, Father Baggot cited other aspects that may have factored into the European trend towards a more cautious application of the Dutch protocol: fear of expensive legal lawsuits and the recognition that the treatments fail to offer the promised peace and integration in patients.

In contrast to risky, ineffective procedures for those experiencing gender dysphoria, Father Baggot emphasized the imperative to provide “psychological and spiritual support needed for the person to come to a deeper integration with his or her biological sex.” 

 “Unfortunately, so-called gender-affirming care is often biological-sex-denying care,” the bioethics expert explained. “The approaches tend to treat the body as a malleable external instrument of a mysterious inner self.” 

“Many teenagers don’t like their bodies and all the changes happening to them during puberty, but that is normal,” Román added, stressing that any experience of bodily discomfort before or during puberty must not be confused with gender dysphoria, although it increasingly is.

Father Baggot said that instead of children feeling pressured to attempt radical alterations of their bodily sex, “they should be taught that there are many valid and beautiful ways to live their masculinity or femininity” — something that, for the time being, seems more possible in progressive European countries than in similarly progressive American states. 

“I hope that Europe’s greater caution in subjecting vulnerable children to risky experimental procedures inspires a new perspective in the United States,” he said. “I doubt that this will happen unless partisan politicians can work past inflammatory rhetoric to find common ground on offering compassionate and science-based care.”

• transgenderism
• catholic europe
• hormone therapy

Bénédicte Cedergren Bénédicte Cedergren is a Swedish-French freelance journalist. After graduating from the University of Stockholm with a degree in Journalism, Bénédicte moved to Rome where she earned a degree in Philosophy at the Pontifical University of Saint Thomas Aquinas. She also sings sacred music and works as a photographer. Passionate about spreading the truth and beauty of the Catholic faith, Bénédicte enjoys sharing the testimonies of others and writing stories that captivate and inspire.

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Introduction

The historic and cultural diversity of gender, biological underpinnings of gender identity, history of modern gender-affirming medical treatment, history of gender-affirming medical treatment in adolescents, changing prevalence of trans identities and the rise of nonbinary identification, legislative and social dynamics, conclusions, statement of ethics, conflict of interest statement, funding sources, author contributions, data availability statement, the evolution of adolescent gender-affirming care: an historical perspective.

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Jeremi M. Carswell , Ximena Lopez , Stephen M. Rosenthal; The Evolution of Adolescent Gender-Affirming Care: An Historical Perspective. Horm Res Paediatr 29 November 2022; 95 (6): 649–656. https://doi.org/10.1159/000526721

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While individuals have demonstrated gender diversity throughout history, the use of medication and/or surgery to bring a person’s physical sex characteristics into alignment with their gender identity is relatively recent, with origins in the first half of the 20th century. Adolescent gender-affirming care, however, did not emerge until the late 20th century and has been built upon pioneering work from the Netherlands, first published in 1998. Since that time, evolving protocols for gender-diverse adolescents have been incorporated into clinical practice guidelines and standards of care published by the Endocrine Society and World Professional Association for Transgender Health, respectively, and have been endorsed by major medical and mental health professional societies around the world. In addition, in recent decades, evidence has continued to emerge supporting the concept that gender identity is not simply a psychosocial construct but likely reflects a complex interplay of biological, environmental, and cultural factors. Notably, however, while there has been increased acceptance of gender diversity in some parts of the world, transgender adolescents and those who provide them with gender-affirming medical care, particularly in the USA, have been caught in the crosshairs of a culture war, with the risk of preventing access to care that published studies have indicated may be lifesaving. Despite such challenges and barriers to care, currently available evidence supports the benefits of an interdisciplinary model of gender-affirming medical care for transgender/gender-diverse adolescents. Further long-term safety and efficacy studies are needed to optimize such care.

The relatively recent recognition of diversity of “gender identity” – one’s inner sense of self as male or female or somewhere on the gender spectrum – in the current culture belies its long-standing presence in cultures diverse and ancient. “Transgender” (sometimes referred to as “gender incongruence”) is defined as a marked and persistent incongruence between an individual’s experienced gender and their sex designated at birth. Transgender is often used as an umbrella term to encompass all gender identities that are not the same as the birth-assigned gender (typically based on the sex designated at birth) but may also be used specifically for a binary gender identification.

As our understanding of gender has been evolving over time, so has the language used to describe gender. Throughout this manuscript, the authors have primarily used the terminology of the present day, though historical descriptions will contain language that is clearly outdated. We have chosen to use these terms only to maintain the historical perspective in this context.

Though it may seem that transgender as a concept is a recent phenomenon, there are both ancient and diverse examples that underscore the understanding that humans have experienced gender as beyond the set of cultural norms assigned to them based on their genitals. In Greek and Roman mythology, there are legends of deities who defy traditional concepts of gender; the most famous may be Hermaphroditus, a son born of Hermes and Aphrodite. When the nymph Salmacis fell in love with him, their forms became merged, with the god depicted as having male genitalia with breasts and a more feminine body shape [1, 2]. Norse mythology gives us the notorious shape and sex shifting Loki, who was known for his trickery, appearing at times in a female form when it suited his purpose [1]. Several Indigenous North American tribes have long-standing recognition and language for gender and/or sexual minority-identified individuals that often signified a third gender, or a combination of male and female. Though the designation and roles varied among tribes, the term “two-spirit” was coined in 1990 during the international LGBT Native American Gathering and attributed to Elder Maya Laramee [3, 4]. This term is not specific to any one tribe or any one group of individuals but encompasses any indigenous member with gender-diverse identification or same-sex attraction.

John Money, a New Zealand psychologist and faculty member in pediatrics at Johns Hopkins University beginning in the early 1950s, and co-founder of the Gender Identity Clinic at that university, promoted the concept that gender identity was influenced by “social learning and memory” in conjunction with biological factors [5]. However, a widely publicized case described in a book by John Colapinto published in 2000 lends strong support to the concept that gender identity is not primarily learned [6]. This book focused on a failed circumcision in an 8-month-old male resulting in loss of the penis, leading Money to advise the family to castrate the infant and raise him as a girl [6]. The child never accepted a female gender identity, became severely depressed, and changed gender to male during adolescence. He later committed suicide [6]. In subsequent years, evidence in support of biological underpinnings to gender identity development has continued to emerge, derived primarily from three biomedical disciplines: genetics, endocrinology, and neurobiology [7].

Starting in the late 1970s, heritability of being transgender was suggested from studies describing concordance of gender identity in monozygotic twin pairs and in father-son and brother-sister pairs [8, 9]. In the largest twin study evaluating gender identity, in which at least one member of a twin pair was transgender, there was a much greater likelihood that the other member of the twin pair was also transgender if they were identical versus nonidentical (but same sex) twins [ 10 ]. Attempts to identify polymorphisms in candidate genes that might be more prevalent in transgender versus cisgender individuals have been inconsistent. In particular, a 2009 study from Japan did not find any significant associations of transsexualism with polymorphisms in five candidate genes (encoding the androgen receptor, CYP19, ER-alpha, ER-beta, and the progesterone receptor) [ 11 ]. However, a 2019 study in 380 transgender women and 344 cisgender male controls demonstrated an over-representation of several allele combinations involving the androgen receptor in transgender women [ 12 ]. A subsequent study using whole-exome sequencing in a relatively small number of transgender males ( n = 13) and transgender females ( n = 17) demonstrated 21 variants in 19 genes that were associated with previously described estrogen receptor-activated pathways of sexually dimorphic brain development [ 13 ]. An association between polymorphisms in the estrogen receptor alpha gene promoter and a transgender male identity has also been reported [ 14 ].

The vast majority of transgender individuals do not have an intersex condition or any associated abnormality in sex steroid production or responsiveness [7]. However, studies in a variety of intersex conditions have informed our understanding of the potential role of hormones, particularly prenatal and early postnatal androgens, in gender identity development [7]. For example, several studies of 46,XX individuals with virilizing congenital adrenal hyperplasia caused by 21-hydroxylase deficiency demonstrated a greater prevalence of a transgender identity outcome (female to male) compared to the general population [ 15-17 ]. One such study published in 2006 demonstrated a relationship between severity of congenital adrenal hyperplasia and gender identity outcome, where 7% of patients with the severe salt-wasting form had gender dysphoria or a male gender identity, while no gender dysphoria was seen in any of the less severely affected individuals [ 16 ]. Studies in a variety of other hormonal and nonhormonal intersex conditions support a role of prenatal and/or postnatal androgens in gender identity development [7]. However, in 2011, a case report in a 46,XY individual with complete androgen insensitivity and a male gender identity challenged the concept that androgen receptor signaling is required for male gender identity development [ 18 ].

Neuroimaging studies that aim to understand the neurobiology of gender identity indicate that some sexually dimorphic brain structures are more closely aligned with gender identity than with physical sex characteristics in transgender adults prior to treatment with gender-affirming hormones [ 19-21 ]. A similar trend was reported in studies of gray matter in youth with gender dysphoria [ 22 ]. In 2021, an MRI study in transgender adults, also prior to treatment with gender-affirming sex hormones, found that transgender people have a unique brain phenotype “rather than being merely shifted towards either end of the male-female spectrum” [ 23 ]. Notably, in both transgender adolescents and adults, several functional brain studies looking at responses to odorous compounds or mental rotation tasks demonstrated that patterns typically observed to be sexually dimorphic were more closely aligned with gender identity than with physical sex characteristics, even before treatment with gender-affirming sex hormones [ 24-26 ].

Though individuals have demonstrated gender diversity throughout history, the use of medication and/or surgery is relatively recent with origins in Germany in the first half of the 20th century and is credited to the pioneering work of Magnus Hirschfeld. The institution he founded, “Institut für Sexualwissenschaft (the Institute for Sexual Science)” in Berlin (1922), paved the way for the use of hormones and surgery [ 27 ]. In Hirschfeld’s study of what he named “sexual intermediaries,” he recognized that people may be born with a nature contrary to their assigned gender. In cases where the desire to live as the opposite sex was strong, he thought science ought to provide a means of transition. Innovative for his time, he argued that a person may be born with characteristics that did not fit into heterosexual or binary categories and supported the idea that a “third sex” existed naturally [ 27 ]. The first documented case of genital surgery was performed at the institute on Dorchen Richter in 1922 with orchiectomy and then 1931 with penectomy and vaginoplasty [ 27, 28 ]. Notable patients, including Lili Elbe (born Einar Wegener), the patient on whom the movie “The Danish Girl” is based, underwent a series of operations including transplant of both ovaries and a uterus [ 29 ].

This clinic would be a century old if it had not fallen victim to Nazi ideology and Hitler’s mission to rid Germany of Lebensunwertes Leben, or “lives unworthy of living.” What began as a sterilization program ultimately led to the extermination of millions of Jews, Gypsies, Soviet, and Polish citizens, as well as homosexuals and transgender people. When the Nazis came for the institute in 1933, Hirschfeld had fled to France. Troops swarmed the building and created a bonfire that engulfed more than 20,000 of his books, some of them rare copies that had helped provide a history for transgender people [ 27 ].

In the 1950s, German-American physician Harry Benjamin (1885–1986) introduced the term “transsexuality,” defining a “transsexual” person as someone who identifies in opposition to their “biological sex” [ 30 ]. Harry Benjamin graduated cum laude from medical school in Tübingen, Germany, in 1912. He moved to New York City in 1914 to study tuberculosis, but over time, he became known as a geriatrician, endocrinologist, and sexologist [ 31 ]. He did not treat his first transgender patient until he was in his 60s, and his colleagues described him as follows: “Being a true physician, Benjamin treated all these patients as people and by respectfully listening to each individual voice, he learned from them what gender dysphoria was about” [ 32 ]. Notably, he did not describe “transsexualism” as a psychological problem, but as a biological condition that could be treated with hormone or surgical therapy [ 31 ]. He treated over 1,500 patients, and in 1966, he published the first medical textbook in this field, “The Transsexual Phenomenon” [ 33 ]. His work was very influential, and he became known as “The Father of Transsexualism” [ 31, 32 ].

Following World War II, gender-affirming treatment in the USA was limited to wealthy patients who could afford to travel to Europe, though they did so at great risk given the laws in several states outlawing “cross-dressing” [ 34 ]. Christine Jorgensen (1926–1989) brought visibility to transgender patients, having undergone medical and surgical transition in Europe after she had served time in the US military as a male [ 35 ].

Influenced by Dr. Benjamin Harris’ “The Transsexual Phenomenon” [ 33 ], Johns Hopkins Hospital in Baltimore became the first academic institution in the USA to offer gender-affirming surgery [ 36 ]. Soon after, at least another 8 academic institutions opened transgender programs throughout the 1960–1970s (University of Minnesota, University of Washington, Northwestern/Cook County Health in Chicago, Stanford University, Cleveland Clinic, University of Colorado, Baptist Medical Center in Oklahoma City, and Washington University in St. Louis) [ 37 ].

Toward the end of the 1970s, however, most transgender programs closed access to new patients. These closures were done quietly out of public view, and the causes were often not disclosed [ 37 ]. At Johns Hopkins Hospital, Paul McHugh became the Chair of Psychiatry in 1975. From the moment he was hired, McHugh openly stated he intended to stop gender-affirming surgery at this hospital [ 38 ]. Under his leadership, another Johns Hopkins psychiatrist, Dr. Jon Meyer, published a study of 50 patients which concluded that gender-affirming surgery did not provide “objective” benefit for transgender individuals [ 39 ]. This publication led to the sudden closure of the clinic in 1979 [ 36 ]. Interestingly, John Money, who believed that gender could be learned and who co-founded the Johns Hopkins gender clinic, publicly expressed opposition to Meyer’s conclusions of his study [ 36 ].

The program at the Baptist Medical Center in Oklahoma City had been functioning since 1973. However, in 1977, its existence was brought to the attention of the Board of Directors of the Baptist General Convention of Oklahoma. This led to a 54-2 vote by the Board of Directors at the Baptist Medical Center to close the program. Physicians who passionately advocated to continue this practice issued a joint statement saying, “If Jesus Christ were alive today, undoubtedly he would render help and comfort to the transsexual” [ 37 ].

It is thought that publicity around the Meyer paper [ 39 ] from Johns Hopkins played a role in an escalation of closure of other clinics [ 37 ]. Despite these closures, academic interest in the field led to the foundation of the Harry Benjamin Gender Dysphoria Association in 1979 [ 40 ]. This association had the goal of organizing professionals who were interested in the “study and care of transsexualism and gender dysphoria.” It has since been renamed the World Professional Association for Transgender Health (WPATH) and has evolved into a large international multidisciplinary organization that provides Standards of Care for the treatment of transgender/gender-diverse (TGD) adolescents and adults [ 41 ].

In 1980, “transsexualism” and “gender identity disorder of childhood” were both recognized as illnesses in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders [ 42 ]. In 2013, the term “gender identity disorder” was replaced by “gender dysphoria in children” and “gender dysphoria in adolescents and adults” to diagnose and treat those transgender individuals who felt distress at the mismatch between their gender identities and their bodies, with the American Psychiatric Association stating that “it is important to note that gender nonconformity is not in itself a mental disorder” [ 43 ].

In 2019, the World Health Organization International Classification of Diseases version 11 replaced International Classification of Diseases-10’s “transsexualism” and “gender identity disorder of children” with “gender incongruence of adolescence and adulthood” and “gender incongruence of childhood,” respectively [ 44 ]. Gender incongruence was moved out of the “Mental and behavioral disorders” chapter into a new chapter, entitled “Conditions related to sexual health” [ 44 ]. This reflects current perspective that TGD identities are not mental health illnesses and that classifying them as such can cause significant stigma.

Providers in the Netherlands recognized the importance of preventing progression of a gender incongruent puberty by using a gonadotropin hormone-releasing hormone analog (GnRHa) followed by treatment with either testosterone or estrogen to bring physical characteristics into alignment with a patient’s gender identity [ 45, 46 ]. This approach was first published by Drs. Cohen-Kettenis and van Goozen in 1998 in a case report of an adolescent treated with GnRHa by Dr. Henriette A. Delemarre-van de Waal (though not named in the publication) (Dr. Sabine E. Hannema , personal communication) [ 47 ]. Under the direction of Dr. Peggy Cohen-Kettenis, the first program geared to treating adolescents with gender dysphoria was established in the Netherlands [ 45 ]. Initially based on the guidelines of adult transgender treatment established by the Harry Benjamin Society and adapted to adolescents, patients first underwent comprehensive psychological assessment to establish a diagnosis of gender dysphoria (then called “gender identity disorder”) and then initiated treatment with GnRH agonists (GnRHa) typically at Tanner 2–3 to pause pubertal development [ 45, 46 ]. The time spent under pubertal suppression would be used to further explore gender identity prior to committing to either estrogen or testosterone and their physical effects. This intervention with a GnRHa would also be somewhat of a diagnostic aid in that if it eased the distress; it was reasonable to correlate the distress with gender dysphoria as a primary cause. This was followed by hormone therapy around age of 16 years and then gender-affirming genital surgery at 18 years or later [ 45, 46, 48 ]. The “Dutch Protocol” [ 49 ] was adapted by practitioners internationally, though it was not until pediatric endocrinologist and adolescent medicine pediatrician Dr. Norman Spack , having traveled to Amsterdam to observe the clinic there, established the first formal US program geared specifically to transgender adolescents at Boston Children’s Hospital: the Gender Management (subsequently replaced with Multispecialty) Service program in 2007 [ 50 ]. It should be noted that adolescents there and elsewhere across the USA had been treated outside of a structured program [ 50 ]. Clinical protocols at Gender Management Service were derived from direct observation, adaptation of the Dutch program, and a May 2005 consensus meeting (the Gender Identity Research and Education Society) and expanded upon previous guidelines from the Standards of Care of the WPATH and those from the Royal College of Psychiatrists [ 46, 51, 52 ].

The Endocrine Society guidelines, with input from the Pediatric Endocrine Society, the European Society for Paediatric Endocrinology, the European Society for Endocrinology, and WPATH, were first published in 2009 and recommended the use of GnRHa as a treatment for selected adolescents [ 53 ]. Pubertal suppression could be initiated when the individual reached Tanner 2 or 3, followed by gender-affirming hormones at age of 16 years. Subsequent standards of care and clinical practice guidelines published by WPATH (SOC 8 in 2022) [ 41 ], the University of California San Francisco in 2016 [ 54 ], and the Endocrine Society (updated in 2017) [ 55 ] continued to recommend treatment for adolescents starting with pubertal suppression at Tanner 2 and 3, with consideration of gender-affirming sex hormones in some adolescents younger than 16 years old (on a case-by-case basis) who had demonstrated strong and persistent gender dysphoria. Of note, the WPATH SOC 8 does not list minimum age requirements for gender-affirming medical care [ 41 ].

In 2014, a published resource guide providing contact information showed that there were 32 US and 2 Canadian programs available to treat TGD adolescents [ 56 ]. As of March 2022, there were about 60 recognized pediatric/adolescent multidisciplinary gender programs in the USA, though smaller programs and individual offices probably also provide care [ 57 ]. Some programs have been closed for political reasons with potentially dire consequences for both patients and practitioners [ 58 ].

Worldwide, the prevalence of people declaring a gender identity that is different from that assigned at birth has risen sharply as the recognition of gender diversity, and its social acceptance has increased. Early estimates of prevalence for those seeking hormonal treatment are notable for relatively low prevalence and a heavy predominance of birth-assigned males. In 1968, two authors published estimates demonstrating this trend. In the USA, Pauly cited 1:100,000 birth-assigned males and 1:400,000 birth-assigned females [ 59 ]. In Sweden, the estimate again favored the birth-assigned males at 1:37,000 and birth-assigned females at 1:103,000 [ 60 ]. By the mid-80s, numbers had risen with a similar ratio of birth-assigned males at 1:18,000 and birth-assigned females at 1:54,000 [ 61 ]. The same year, authors in Singapore reported much higher numbers of 1:2,900 and 1:8,300 birth-assigned males and females, respectively [ 62 ]. The Williams Institute of the University of California Los Angeles School of Law has tracked prevalence of transgender identification in the USA. A report from 2022 (based on data from 2017, 2019, and 2020) revealed that the prevalence of adults in the USA who identified as transgender has remained stable at around 0.5% of the population, or 1.3 million adults. However, the percentage of trans-identified youth (ages 13–17) had notably increased in recent years from 0.7% to 1.4% of the population [ 63 ]. Recent reports have also noted a rise in nonbinary gender identification and a reversal in the sex ratio of adolescents presenting for gender-affirming care from a predominance of those designated male at birth to a predominance of individuals designated female at birth. In 2017, a large adolescent multidisciplinary survey noted that 63% of the presenting patients were birth-assigned females [ 64 ].

Since 2016, many US states and European countries have introduced laws that restrict transgender youth from accessing gender-affirming care, team sports, and restrooms that are consistent with their gender identity [ 65 ]. Simultaneously, numerous reputable national and international academic medical societies have openly and repeatedly stated their opposition to these laws. This includes the Pediatric Endocrine Society [ 66, 67 ], the Endocrine Society [ 68, 69 ], the American Academy of Pediatrics [ 70 ], the American Medical Association [ 71 ], the United States Professional Association for Transgender Health [ 72 ], the American Association for Child and Adolescent Psychiatry [ 73 ], and in a united statement, also the American Psychiatric Association, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, and the American Osteopathic Association [ 74 ].These societies have stated that these bills are discriminatory and cause harm to the mental health of transgender youth. Despite this, some bills have passed successfully [ 65 ].

While there is a long-standing history acknowledging the existence of human gender diversity, the history of gender-affirming medical care for adolescents, in particular, is relatively brief. Evolving protocols for gender-diverse adolescents, first pioneered in the Netherlands, have been incorporated into clinical practice guidelines and standards of care published by the Endocrine Society and WPATH, respectively, and have been endorsed by major medical and mental health professional societies around the world. Notably, however, while there has been increased acceptance of gender diversity in some parts of the world, transgender adolescents and those who provide them with gender-affirming medical care, particularly in the USA, have been caught in the crosshairs of a culture war, with the risk of preventing access to care that published studies have indicated may be lifesaving. Despite such challenges and barriers to care, currently available evidence supports the benefits of an interdisciplinary model of gender-affirming medical care for transgender adolescents. Further long-term safety and efficacy studies are needed to optimize such care.

Not applicable as this is a historical report and not a report of research.

Jeremi M. Carswell, Ximena Lopez, and Stephen M. Rosenthal declare no conflicts of interest.

This work has not received any funding or financial support.

Jeremi M. Carswell, Ximena Lopez, and Stephen M. Rosenthal contributed equally to the writing of the manuscript. Jeremi Carswell and Ximena Lopez are the co-first authors, and Stephen M. Rosenthal is the senior and corresponding author.

There were no data generated for this report.

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Sweden puts brakes on treatments for trans minors

Stockholm (AFP) – Sweden, the first country to introduce legal gender reassignment, has begun restricting gender reassignment hormone treatments for minors, as it, like many Western countries, grapples with the highly-sensitive issue.

Issued on: 08/02/2023 - 07:34 Modified: 08/02/2023 - 09:45

With the number of diagnoses soaring, the medical community faces the dilemma of weighing precaution against the risks associated with not offering treatment to those suffering from "gender dysphoria".

Sweden decided in February 2022 to halt hormone therapy for minors except in very rare cases, and in December, the National Board of Health and Welfare said mastectomies for teenage girls wanting to transition should be limited to a research setting.

"The uncertain state of knowledge calls for caution," Board department head Thomas Linden said in a statement in December.

So-called puberty blockers have been used in young teens contemplating gender transition to delay the onset of unwanted physical changes.

Like many other countries, Sweden has seen a sharp rise in cases of gender dysphoria, a condition where a person may experience distress as a result of a mismatch between their biological sex and the gender they identify as.

According to the Board of Health and Welfare, approximately 8,900 people were diagnosed with gender dysphoria in Sweden between 1998 and 2021, in a country of around 10 million.

In 2021 alone, about 820 new cases were registered.

The trend is particularly visible among 13- to 17-year-olds born female, with an increase of 1,500 percent since 2008.

"It used to be a male phenomenon and now there is a strong female over-representation," psychiatrist Mikael Landen, chief physician at Sahlgrenska University Hospital in Gothenburg, told AFP.

Landen, who contributed to the scientific study on which the Board of Health based its decision, said the reasons for this increase remain largely a "mystery".

"Tolerance has been high in Sweden for at least the last 25 years, so you can't say it has changed," he said when asked if it was simply a result of a more accepting society.

Western debate

The profile of those diagnosed is often complex, according to Linden, as gender dysphoria often occurs in those also suffering from other diagnoses, such as attention deficit and eating disorders or autism.

In May 2021 -- before the Swedish authorities' decision to restrict gender reassignment hormone treatments -- the prestigious Karolinska Hospital in Stockholm chose to restrict such hormone treatments to research projects only.

Other countries are weighing the same questions.

Neighbouring Finland took a similar decision in 2020, while France has called for "the utmost reserve" on hormone treatments for young people.

The UK meanwhile saw a high-profile court case in 2020.

Keira Bell, who regretted her transition from female to male, filed a complaint against the public body responsible for gender dysphoria treatments, claiming she had been too young at age 16 to consent to the treatments.

She ultimately lost her case.

Sweden's recent rollback is all the more notable as it was first in the world to authorise legal gender transition in 1972, paving the way for sex reassignment surgery to be covered by its universal healthcare system.

Rights groups have expressed concern.

Elias Fjellander, president of the youth branch of RFSL, the country's main organisation championing LGBTQ rights, says Sweden's decision risks leading to increased suffering.

"These people might need more care and invasive procedures in the future, because the decision could not be made earlier, even though the medical need was there," he said.

Twenty-year-old Antonia Lindholm, a trans woman who began her transition as a teenager, agreed.

"I think hormones save a lot of people," she told AFP.

"If I were 13 today, I wouldn't have a chance" of getting this treatment, Lindholm added.

But others who have had hormone treatment support the Swedish position.

Mikael Kruse, 36, changed his gender in his late 20s but had a change of heart and finally "detransitioned".

"I think it's good to take a break to understand what's going on," he told AFP.

For seven years, the Swede lived as a woman, but that never resolved his discomfort.

A new diagnosis revealed he had Asperger's Syndrome as well as Attention Deficit Disorder, and the suffering he thought was related to his gender was due to different factors.

"All the pieces of the puzzle fell into place," Kruse said.

For Carolina Jemsby, co-director of the Swedish documentary The Trans Train which brought the care of adolescents into the limelight in 2019, the current debate shows it is "more complex than the healthcare system and society had hoped".

"One aspect of this dilemma is that it has become a political issue," she told AFP.

"It does a disservice to this group who need scientifically proven medical care to help them and give them a better life, and a better ability to live who they are."

In 1972 Sweden introduced an act to allow people to legally change their gender thus becoming, according to the government, "the first country in the world to introduce a formal option in law to be assigned with a new legal gender".

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FACT CHECK: Is The Rate Of Regret After Gender-Affirming Surgery Only 1%?

A post shared on social media  claims only 1% of people regret their gender-affirmation surgery.

  View this post on Instagram   A post shared by matt bernstein (@mattxiv)

Verdict: Misleading

While the study cited does find a 1% regret rate, it and other subsequent studies share disclaimers and the limitations of research, suggesting the rate may actually be higher.

Fact Check:

The Instagram post claims that only 1% of patients regret their gender transition surgeries. The source used is “Regret after Gender-affirmation Surgery: A systematic Review and Meta-analysis of Prevalence” from the National Library of Medicine (NLM).

The caption is misleading, due to several factors and lack of research that were identified by the study itself and other subsequent papers. (RELATED: Did Canada Release A New Passport That Features Pride Flags?)

This study did not conduct original research, but rather compiled research done in many different places which resulted in a disclaimer warning of the danger of generalizing the results. “There is high subjectivity in the assessment of regret and lack of standardized questionnaires,” which varies from study to study, according to the NLM document.

The study quotes a 2017 study published in the Journal of Sex and Marital Therapy , which conducted a follow-up survey of regret among patients after their transition. The study notes a major limitation was that few patients followed up after surgery.

“This study’s main limitation was the sample representativeness. With a response rate of 37%, similar to the attrition rates of most follow-up studies,” according to the study. Out of the response rate, six percent reported dissatisfaction or regret with the surgery, the study claims.

Additional data found in a Cambridge University Press study showed subjects on average do not express regret in the transition until an average of 10 years after their surgery. The study also claimed twelve cases out of the 175 selected, or around seven percent, had expressed detransitioning.

“There is some evidence that people detransition on average 4 or 8 years after completion of transition, with regret expressed after 10 years,” the study suggests. It also states that the actual rate is unknown, with some ranging up to eight percent.

Another study published in 2007 from Sweden titled, “ Factors predictive of regret in sex reassignment ,” found that around four percent of patients who underwent sex reassignment surgery between 1972-1992 regretted the measures taken. The research was done over 10 years after the the procedures.

The National Library of Medicine study only includes individuals who underwent transition surgery and does not take into account regret rates among individuals who took hormone replacement. Research from The Journal of Clinical Endocrinology and Metabolism (JCEM) found that the hormone continuation rate was 70 percent, suggesting nearly 30 percent discontinued their hormone treatment for a variety of reasons.

“In the largest surgery study, approximately 1% of patients regretted having gender-confirmation surgery,” Christina Roberts, M.D, a professor of Pediatrics at the University of Missouri-Kansas City School of Medicine and a participant for the study for the JCEM, told Check Your Fact via email.

Roberts stated that while there were multiple major factors in regards to those regretting the surgery, including poor cosmetic outcome and lack of social support, she claimed discontinuation of hormone therapies and other treatment are “not the same thing as regret.”

“This is an apples to oranges comparison,” Roberts added. (RELATED: Is Disney World Replacing The American Flag With The LGBTQ+ Pride Flag In June 2023?)

Check Your Fact reached out to multiple doctors and researchers associated with the above and other studies and will update this piece if responses are provided.

Joseph Casieri

Fact check reporter.