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SEGM

@segm_ebm

Jul 19

A new study of insurance records from Germany suggests that the diagnosis of gender dysphoria in youth aged 5-24 is usually not permanent. Over 60% of youth diagnosed with "Gender Identity Disorder" no longer have the diagnosis after 5 years. /1

segm.org/gender-dysphor…

Like other Western countries, Germany has experienced a rapid rise of gender dysphoria in young people in the last decade. Adolescent females have the highest prevalence of gender dysphoria, increasing 12-fold in a decade. /2

Besides the low diagnostic stability of the diagnosis of gender dysphoria in adolescents/young adults, other notable finding are that young adults are similarly affected as adolescents, and that overall gender dysphoric youth have higher rates of mental health co-morbidities./3

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SEGM

@segm_ebm

Jun 20

The World Health Organization @WHO just announced its updated plans for the transgender guidelines. The new deadline to comment is July 5th. This timing is challenging, as it coincides with the UK & French elections and the US Independence Day celebrations.

As stated previously, the upcoming guideline will address the care for gender-dysphoric adults, who, like all patients, deserve access to evidence-based care informed by evidence-based clinical practice guidelines. The Cass Report identified the group of gender-dysphoric young adults as a key vulnerable group. England has initiated a Cass-style inquiry into the care for this vulnerable population.

In this context, proceeding with developing guidelines that bypassed systematic evidence reviews, and instead will rely on WHO's previous HIV-focused recommendations that promote wide access to hormones (as WHO's documentation suggests), is alarming.

/1

who.int/news/item/20-0…

The prior guideline development group (GDG) composition was called out for being biased. A cursory review of the updated GDG suggests that members with conflicts of interests will continue to serve on the GDG, but several new members have been added. /2
who-decides.org

Importantly, no process changes have been announced, despite the profound problems in the process we wrote about:/3
segm.org/WHO-TGD-Guidel…

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SEGM

@segm_ebm

May 10

The 128th German Medical Assembly 2024 just passed 2 resolutions: to restrict puberty blockers, cross-sex hormones, and surgeries for gender-dysphoric youth under 18 to controlled clinical trials; and to restrict the self-id laws to those over 18. This is a major development. /1

The first resolution focuses on "gender-affirming care" for youth. The resolution, upvoted by the majority of physician delegates, stated:

"The 128th German Medical Assembly 2024 calls on the Federal Government to only permit puberty blockers, sex-change hormone therapies or gender reassignment surgery in under 18-year-olds with gender incongruence (GI) or gender dysphoria (GD) in the context of controlled scientific studies and with the involvement of a multidisciplinary team and a clinical ethics committee and after medical and, in particular, psychiatric diagnosis and treatment of any mental disorders.
The therapy results of any interventions of this kind must be followed up sociologically, medically, child and adolescent psychiatrically, socially and psychologically over a period of at least ten years and the evaluation results incorporated into the revision of the
'Guideline on gender incongruence and gender dysphoria in childhood and adolescence:
diagnosis and treatment.' "

The justification stated:

"The current medical evidence clearly and unambiguously states that puberty-blocking drugs
(PB), opposite-sex hormone treatments (so-called cross-sex hormone administration [CSH]) and gender reassignment surgery (e.g. a mastectomy) do not improveGI/GD symptoms or mental health in minors with GI/GD. These are irreversible interventions in the human body in physiologically primarily healthy minors, who cannot give informed consent in the absence of evidence for such measures. Such interventions also
influence the human psyche, especially in minors during their development.

Most minors who receive PB and CSH later wish to have sex surgery. The use of interventions such as PB or CSH administration is a form of experimental medicine on children, which is very likely to be followed by interventions in the child's body, such as the amputation of the breast or penis, and which result in the loss of reproductive capacity and a reduction in the ability to experience sex, including anorgasmia.

A child or adolescent is not in a position to decide for themselves - without medical advice and parental consent - on the use of PB or CSH before the end of puberty and the physical maturation process and before the age-typical age-role conflicts or body image disorders of puberty have been overcome, especially in the absence of medical evidence for their
respective clear and sustainable benefits in this very population.

Gender or sex dissatisfaction is most common at around the age of eleven, and the frequency of this
symptomatology then decreases with age. The clear majority of minors show no persistent gender or sex dissatisfaction over the course of their lives.

The administration of PB, CSH and the performance of gender reassignment surgery must not be made dependent solely on the will of a developing child or adolescent. Given the existing evidence on the treatment of GI/GD, concern for the child's welfare must
prevail. " /2

The second resolution dealt with self-id laws and resolved that minors should not be allowed to "self-identify" into a chosen sex without a prior specialist child and adolescent psychiatric diagnosis and consultation.

It resolved:

"The 128th German Medical Assembly 2024 calls on the Bundestag to amend the Self- Determination Act to the effect that under-18s may not be permitted to provide or have provided information on their gender and marital status in the personal register without prior specialist child and adolescent psychiatric diagnosis and consultation".

The justification stated:

On 12.04.2024, the Bundestag passed the law on self-determination with regard to gender registration (so-called Self-Determination Act). It provides for the repeal of the Transsexuals Act (TSG), which has been in force since 1981. Contrary to the recommendation of the German Medical Association, the change of gender entry and first names for "transgender" as well as "non-binary" and intersex persons will be regulated in a joint administrative procedure, i.e. no longer in two different laws, each with different requirements, as was previously the case. It was decided that, in future, every person who has reached the age of 14 will be able to undergo a transsexual transition. The child should be able to obtain a legally binding declaration from the registry office that the information on their gender and marital status in the register of persons is replaced by another designation or deleted - unconditionally, i.e. without any examination of the seriousness, truthfulness and permanence of the wish and without an obligatory psychiatric-psychotherapeutic consultation. For a person who is legally incapable or has not yet reached the age of 14, their legal representatives should make the declaration. In the event that the latter refuse to do so, the declaration should be made by the family court as an alternative, provided that the change of gender and first names is not contrary to the best interests of the child.

From a medical, sexological and biological perspective, a person's gender is a reality that can be determined on the body and in the vast majority of cases is unambiguous, not freely available, but unchangeable. Gender is biologically binary, and the concept is
separate from that of gender identity. In rare cases, a person's subjectively perceived gender identity deviates from their objectively given physical gender. The Self-
Determination Act attempts to find a solution to the associated internal conflict (gender incongruence) and a problem of primary procedural law by equating the category of gender under civil status law - logically inconclusive - with the psychological construct of
"gender identity". This should be criticized:

-the lack of differentiation between a person's subjective sense of belonging, including the self-categorization derived from this, and their actual physical-biological gender,

-the equation of gender identity and civil status in the official birth register,

-the inadequate differentiation between intersexuality/DSD ("variants of sex development") and transsexuality.

From a medical/psychotherapeutic and sexological point of view, civil status law is not the right instrument to guarantee the self-determination of people affected by gender incongruence, to promote their egalitarian treatment and to protect them from discrimination
in everyday life. " /3

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SEGM

@segm_ebm

Apr 11

We've completed our preliminary analysis of the Cass Report. The "gender-affirming" model of care is over in England, as is the era of the gender-clinic model of care, which exists to deliver youth transitions. This will have world-wide implications./1

segm.org/Final-Cass-Rep…

Puberty blockers will no longer be part of medical care in England. Cross-sex hormones are still available to 16+, but with "extreme caution," external validation of medical necessity, & further policy restrictions are likely. Systematic reviews support these recommendations. /2

Gender-transition surgeries for <18s have never been allowed in England, so no systematic reviews of surgeries for youth have been conducted and no policy changes are needed. /3

Read 13 tweets

SEGM

@segm_ebm

Apr 8

Last week, England shut down the world’s largest pediatric gender clinic at the Tavistock (GIDS). Investigative journalist Hannah Barnes shares 7 lessons for the rest of the world at @segm_ebm NYC conference.
Lesson 1: When new evidence emerges, be prepared to change direction.

By now, the science in the area of gender medicine is widely recognized as “unsettled” due to poor study designs—but this was known from the start. This is why the UK gender clinic initiated its own research in 2011. But instead of waiting for research results, the clinic began to widely offer gender transitions to all youth who desired it.

This pattern of the gender-affirming interventions "escaping the lab" before the benefits and the harms were fully understood (known as "runaway diffusion") occurred not just in the UK, but also in the rest of the world.

Some speculate that it was the pressure to "keep up with the Dutch." Others note the role of special interest groups in creating undue pressure on clinicians. Yet others believe it was simply the case of a “well-meaning but ill-informed” approach. /1

At the same time as youth gender transitions became widely available, the numbers of referred gender distressed youth began to rapidly grow. Unexpectedly, the profile shifted from mostly young boys, to mostly adolescent females with serious mental health problems.

It was clear from the start that the young patients presenting with gender distress were far more complex than the cases described in the Dutch protocol. This did not deter gender clinicians, who asserted every child who wanted to medically gender transition should be assisted in doing so, regardless of their mental illness or other complexities. /2

By 2016, the UK gender clinic had enough outcome data to observe two problematic results. Contrary to the expectation, the kids were NOT doing better psychologically on puberty blockers, and some even got worse. These data remained unpublished for 5 years, as more and more children continued to receive these interventions. /3

Read 14 tweets

SEGM

@segm_ebm

Apr 4

A new publication concludes that puberty blockers for gender dysphoria undermine a child’s right to an open future, a bioethics principle stating that children must be protected from exercising certain rights to exercise these rights as autonomous adults./1
segm.org/puberty-blocke…

The authors "evaluate claims that puberty blockers are reversible, discuss the scientific uncertainty about long-term benefits and harms, summarize international developments, and examine how suicide has been used to frame puberty suppression as a medically necessary, lifesaving treatment."

They conclude that "treatment pathways that delay decisions about medical transition until the child has had the chance to grow and mature into an autonomous adulthood would be most consistent with the open future principle." /2

The authors note that under the gender-affirming care framework, a normal physiological process of puberty is viewed as a disease that must be treated with endocrine and surgical treatments. The use of puberty blockers, the first step in this "cascade" of interventions, rests on two assumptions: "(1) puberty blockers are a low-risk, reversible intervention, and (2) suppressing puberty will improve physical and psychological outcomes in later life."

The authors examine these assumptions and find them to be unsupported by the evidence. Puberty blockers are associated with substantial harms and profound unknowns (e.g., bone, brain, fertility, and sexual function harms), and there is no compelling evidence that they improve psychological outcomes.
/3

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