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

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

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

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

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

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

Dr. Kaltiala just won Finland's most prestigious medical award for her work in adolescent psychiatry. Dr. Kaltiala was a speaker at @segm_ebm's NYC conference, where she described how the Finnish youth gender services moved away from the "gender-affirmative" model of care. 🎉/1
In her acceptance speech, Dr. Kaltiala discussed how current cultural trends undermine healthy adolescent development. "The slow development towards the authentic self turns into a lightning-fast self-presentation on social-media forums that are always under observation."

Dr. Kaltiala observed that "a stable, developed identity enables an individual to have a permanent self-experience from one situation and life stage to another, as well as to maintain a sense of permanence and psychological ability to function even in the face of adversity." She noted that "too much focus on the individual and individuality disconnects from stabilizing communities and shared realities." /2

laakarilehti.fi/terveydenhuolt…

The @NHSEngland landmark decision to stop using puberty blockers for gender dysphoric youth raises a key question: what do we know about the effects of puberty blockers on adolescent development?
Prof. Sallie Baxendale explored this question at @segm_ebm 2023 conference./1🧵 "Extraordinary claims demand extraordinary evidence" wrote Prof. Baxendale in a piece describing her research. "The only extraordinary evidence here is the gaping chasm of knowledge, or even apparent curiosity, of the clinicians who continue to chant 'safe and completely reversible' as they prescribe these medications to the children in their care." /2
unherd.com/2024/02/why-di…

Canada's public broadcaster aired a new documentary, Trans Express, underscoring the growing international concern with the practice of youth gender transitions. SEGM's NYC 2023 conference was profiled. /1

Full documentary (in French):
Synopsis (in French, but can be google-translated): ici.tou.tv/enquete
ici.radio-canada.ca/recit-numeriqu… The documentary interviewed several speakers from SEGM's NYC 2023 conference, including Drs. Anderson, Kaltiala, Landen, Littman, and Veissiere. /2

segm.org/NYC_2023

The American Psychological Association @APA has called for "efforts to address and rectify the dissemination of false information to ensure the well-being and dignity of transgender, gender-diverse, and nonbinary individuals."

It should heed its own advice. 🧵 /1 The APA's call for "the importance of an accurate understanding of evidence-based care" is welcome. Yet, the APA's definition of evidence-based medicine (EBM) bears no resemblance to how EBM is either understood or practiced in every other medical field in the 21st century. /2

Our recent Spotlight highlights a study from Finland, which convincingly demonstrates that suicides are uncommon in gender-dysphoric youth. The study demonstrates why youth gender transitions can’t be justified by the “suicide-prevention” argument./1

segm.org/Suicide-Gender… Using a robust methodology, the study estimated the suicide rate for GD youth at 0.3% (0.51/1,000 pt-yrs), with no evidence that transition reduced suicides. In summarizing clinic-reported rates, we noted that the highest suicide rates are coming from the transitioned cases./2

On Jan 15, @WHO amended its previously described plans for "trans" (TGD) treatment guidelines. This was a response to worldwide concern about the effort's credibility. What makes guidelines trustworthy? An expert at SEGM's 2023 conference explains./1
Not all guidelines that claim to be evidence-based, are. Many are "consensus" guidelines developed using the "GOBSAT" method: good old boys sat around the table. This acronym was coined by a former WHO guideline expert who worked to promote rigor in guideline development. /2

The World Health Organization has announced the complete panel developing transgender health guidelines in 2024. The panel's unmanaged conflicts of interest will undermine the guidelines' credibility. Public comment deadline (hiv-aids@who.int) is Jan 8. /1 segm.org/world-health-o… Besides a biased panel, 2 other key concerns are a short public comment period held over the Xmas & New Year's holiday, and a rushed guideline development process, with the group already scheduled to meet in February at the @WHO headquarters in Geneva to make decisions. /2

Do puberty blockers improve mental health? The original Dutch studies claimed so, but a replication attempt in the UK failed, finding no impact. A new peer-reviewed reanalysis of the UK data shows that up to 34% of youth actually "reliably deteriorated"./1
tandfonline.com/doi/full/10.10… The original conclusions of the Dutch research in 2011/2014 claimed modest improvements in mental health of gender dysphoric minors following puberty blockers. The study's actual conclusions were quite modest yet they launched the practice of youth gender transitions worldwide./2

The debate over the practice of youth gender reassignment has reached the Netherlands, the birthplace of the Dutch Protocol. Our spotlight profiles the latest medical, legal & cultural Dutch debates. The significance of this debate cannot be overstated./1
segm.org/Dutch-protocol… Like other Western teens, the Dutch youth began to seek gender transition in record numbers starting mid 2010's. As numbers surged and sex ratios flipped to favor females, the explanations that this shift merely reflects “more freedom to come out" kept the Dutch debate at bay./2

The journal of the Danish Medical Association Ugeskrift for Læger has confirmed that Denmark is restricting medical transition of gender-dysphoric minors. Only 6% of the gender clinic referrals were approved for transition in 2022, down from 65% in 2018./1
segm.org/Denmark-sharpl… While the Danish Minister of Health, Sophie Løhde, already suggested that youth with post-pubertal onset of gender dysphoria or mental health problems won't be medically transitioned, the recent publication provides the rationale for this practice shift./2
https://t.co/8uAAwRZrWYugeskriftet.dk/videnskab/sund…

The claim that youth whose breasts are removed "can always get them later" contributes to the U.S. gender medicine establishment's promotion of mastectomies for minors 12-13+. However, the surgical technique in masculinizing mastectomy makes reversals unfeasible in most cases. /1 As our Spotlight explains, unlike mastectomies for breast cancer, masculinizing mastectomies' focus on nipple repositioning, lower breast pole shape, and scar placement makes a successful breast reconstruction unlikely for most, and cost-prohibitive. /2
segm.org/long-term-regr…

Our latest Spotlight focuses on research from Denmark, which found that trans-identified individuals have a significantly elevated rate of suicide attempts, suicide-related deaths and non-suicide-related deaths, as compared to the general population. /1
segm.org/transgender_su… The study data allow to calculate the "number needed to treat," or the "NNT." A clinician would need to treat 1,333 trans-identifying individuals for a year to encounter 1 suicide death. However this is not the NNT, as gender transition has not been shown to reduce suicides /2.

According to the NHS England's final interim specifications for treating gender dysphoric (GD) youth, published earlier today, the primary intervention for GD children & young people <18 will be psychosocial & psychological support and intervention. /1 england.nhs.uk/publication/in… twitter.com/i/web/status/1… The main objective of the intervention is to alleviate distress associated with gender incongruence & promote the individual’s global functioning and wellbeing. Clinicians are reminded that trans identification may be a transient phase for many youth. /2

A systematic evidence review by the Swedish health authority has just been published in an English-language peer-reviewed journal. It concluded that puberty blockers & cross-sex hormones in <18s are not a medical treatment but experimental procedures./1

onlinelibrary.wiley.com/doi/10.1111/ap… The Swedish-language version of this review was published on the SBU site in February 2022. The review was conducted in order to update Sweden's national guidelines for gender dysphoria treatments. The updated guidelines were published in December 2022. /2
sbu.se/contentassets/…

A new article, Current Concerns About Gender-Affirming Therapy in Adolescents, provides an overview of the current state of evidence about gender transition in youth in the Western world and discusses the debates surrounding this controversial practice./1
segm.org/current-concer… twitter.com/i/web/status/1… The key challenge is the unknown long-term outcomes of gender-transitioning youth. Since transitioning minors was uncommon before 2015, systematic reviews of evidence of youth outcomes are limited by short-term followup. Long-term studies of adults, however, signal problems. /2