Blowback
An activist guide for paediatricians in Italy has, for the first time, roused many clinicians from silence and galvanised them into open opposition to the affirmative treatment model.
Transition for toddlers
Italy | An affirmation-only guide, which offers a case study of social transition for a three-year-old Italian boy and advises paediatricians to refer teenagers to gender clinics “without judging” their requests, has had an unexpected effect.
It has driven a fast-growing online petition that stresses the lack of evidence for the gender-affirming treatment model and proposes careful diagnostic exploration when a young person declares an identity at odds with biological sex. It is the first time that a substantial number of Italian health practitioners have openly challenged the affirmative treatment model, according to the parents’ group GenerAzioneD.
The authors of the gender-affirming guide—issued by the Italian Paediatric Society and the Cultural Association of Paediatricians under the title Beyond the Gaze: A Practical Guide to Gender Variance, Sexual Orientations and Same-Sex Parenting for a Welcoming Paediatric Clinic—have felt the need to publish a Q&A “technical document” in response to the critique of the petition.
At the time of writing, more than 500 practitioners have signed the July 22 petition, calling on the Paediatric Society to rethink its activist guide1. The petition, with the title First, Do No Harm: Science Beyond the Gaze, will also be sent to Italy’s Health Minister, Professor Orazio Schillaci.
Signatories include child neuropsychiatrists, physicians, bioethicists, nurses, midwives, psychiatrists, psychologists, psychotherapists and paediatricians. An additional 500-plus signatories come from the general public.
It began in Berlin: Zhenya Abbruzzese traverses the history of transgender medicine
Breaking the silence
A Meloni government draft law to impose stricter controls over puberty blockers and cross-sex hormones for minors has yet to be discussed in Parliament, and health professional societies who issued an endorsement of pubertal suppression in February 2024 have ignored analysis of the flaws in their case.
“Against this backdrop of substantial institutional inaction, we believe this [petition] sends an important signal, as it breaks a long silence and draws the attention of the Italian medical community to the need to engage with the most up-to-date scientific evidence and the evolving international debate,” a member of GenerAzioneD told GCN.
The July 22 petition says: “The ethical and legal responsibility of healthcare professionals, in the light of current scientific evidence, entails not automatically accepting every self-defined identity as definitive, particularly during childhood, but rather supporting the child on a journey towards understanding and integrating their own psychophysical reality.”
“From a psychological perspective, steering a child towards ‘social affirmation’ [or social transition] at an early age … cannot be regarded as a neutral act devoid of potential developmental consequences, as it requires parents and teachers to permanently adopt a specific interpretation of identity whilst the child’s developmental process is still ongoing.”
Point of no return
The affirmation of a three-year-old is “unthinkable” and “would merit attention from the Italian health authorities,” according to the Head of the Independent Authority for Children and Adolescents, Marina Terragni, who is also a feminist and former journalist.
“Social transition, as a response to a possible period of uncertainty—an extremely common experience in the lives of children and adolescents—has all too often proved to be a point of no return, the starting point for so-called ‘affirmative therapy’, which progresses from puberty blockers to cross-sex hormones and surgery by the age of 16,” Ms Terragni said.
She noted the rise of “critical reflection” on the affirmative approach internationally and the shift to caution elsewhere in Europe, with the current advice to prioritise “a holistic approach and a thorough psychological assessment to rule out any psychiatric co-morbidities”.
“The hope is that the guide published by [the Paediatric Society] may provide an opportunity to launch a wide-ranging scientific debate in Italy too, led by the highest health authorities, which takes into account the latest international scientific findings on the subject of dysphoria in children and young people, whilst keeping the best interests of the child firmly at the centre.”
The Society’s guide claims that “social affirmation” of children “is reversible and has no medical implications; it is the only intervention recommended for the prepubertal period”. Although the guide does not mention puberty blockers or cross-sex hormones, the designated role for paediatricians includes the referral of adolescents to specialist gender clinics.
The Society’s technical document says paediatricians are not expected to “make specialist diagnoses or to determine treatment pathways” but to “refer without judging, exaggerating or downplaying requests for help”.
The guide itself notes that the “depathologised” term “gender incongruence” remains in the ICD-11 diagnostic system in order “to ensure access to healthcare pathways for gender affirmation, if desired”. Gender incongruence does not require the distress that went with “gender dysphoria”.
The anonymised case study of “Anna”, a boy who has been trans-identified since the age of 3, poses a dilemma when school starts: there is “an inappropriate request for diagnostic certificates to allow the child to wear the white school smock for girls”.
“The paediatrician intervenes, clarifying that the child does not present with clinical distress (gender dysphoria), but rather a gender variance … An alias is therefore established to address the issues relating to the use of her registered name, the school uniform and the use of school toilets.”
In the case study of “Liam”, a 15-year-old girl who binds her chest, the paediatrician stresses the importance of the mother “accepting her son’s identity” and offers her information about “multidisciplinary care at specialist centres dedicated to gender incongruence”, namely gender clinics. The father, who does not go along with his daughter’s male role, is blamed for “contributing to a conflictual family atmosphere”.
An introduction to the guide says: “Expressions such as ‘It’s just a phase’, ‘You’re too young to know’ or ‘You’ll see, it’ll pass’ … risk conveying a sense of devaluation or inadequacy at a stage of development when being listened to and feeling trusted are fundamental.”
The Paediatric Society’s guide makes no mention of the UK Cass Review, Sweden’s systematic review, Finland’s robust research or the Gender Dysphoria Report from the US Department of Health and Human Services—all of which found the evidence base to be weak, thereby undermining gender-affirming dogma.
The guide does cite the 2022 guideline from the scandal-plagued World Professional Association for Transgender Health, which abandoned minimum ages for hormones and surgery.
In its technical document, the Paediatric Society claims that systematic reviews of puberty blockers and hormones were not cited by the guide because it is not a clinical practice guideline. Systematic reviews are the “gold standard” for evaluating the quality of evidence for treatment.
The systematic reviews commissioned by Dr Cass’s UK inquiry included psychosocial support, social transition, and the characteristics of young people referred to specialist gender clinics, including in Italy—all topics relevant to the Paediatric Society’s guide. Systematic reviews of blockers and hormones for minors are also relevant because the Society is urging its members to refer teenagers to gender clinics.
Critical mass
The July 22 petition, which began with 300 signatures and took off by word of mouth, is unprecedented, according to the parents’ group GenerAzioneD, which played a co-ordinating role.
“To date, in Italy, critical stances towards the affirmative approach to gender dysphoria in children and adolescents have been largely isolated and individual,” a member of the group said.
“This is the first document signed by such a significant number of healthcare professionals who, by giving their full names, are taking a public stand.
“The signatories are calling on the Italian Paediatric Society to reconsider the guidance in the light of the most recent systematic reviews of the international literature and the shift in approach currently being observed in a growing number of European countries.”
The petition echoes the guide’s wish to reduce stigma and discrimination but warns that a single-minded focus on gender identity means “losing sight of the overall clinical picture”.
“[This] must not result in protocols that, in effect, curtail the paediatrician’s clinical freedom, thereby discouraging diagnostic exploration, the assessment of co-morbidities and the adoption of a differentiated, case-by-case approach,” the petition says.
The petition notes that psychiatric problems, personality disorders, autism and ADHD often predate or accompany gender dysphoria, making it hard to discern the direction of causality.
“There is a real risk of diagnostic overshadowing, that is, of reducing the young person’s entire suffering to the sole dimension of gender, whilst neglecting other primary diagnoses that warrant treatment.”
The petition argues that neurodiverse conditions cannot be attributed to “minority stress”, a concept used by gender-affirming clinicians to explain psychiatric conditions in trans-identified patients as the internalised product of an intolerant and bigoted society.
“In the light of current scientific knowledge, empathetic and non-judgemental care means, for the paediatrician, not to recommend affirmative approaches at an early stage, [because the] outcomes in terms of safety and efficacy are unclear,” the petition says.
Instead, the role of the paediatrician should be “to create a context of pause and reflection, providing appropriate information, highlighting the necessary precautions and the potential risks associated with such approaches, as well as the important role of co-morbidities in this context.
“An approach that is truly centred on the child’s wellbeing protects their dignity and their right to be included in a multidisciplinary assessment, without, however, rushing the process of cognitive maturation or promoting premature social or medical interventions in the absence of solid and widely accepted evidence.”
For brevity, I have referred to the guide as the work of the Italian Paediatric Society; it was issued jointly with the Cultural Association of Paediatricians, which is a smaller, more recently founded organisation.