Dutch doubt

A baffling response from the Amsterdam clinic; US judges uphold trans surgery; Australia's undocumented surge in gender medicine; some German guideline dissent; treatment caution catches on in Europe

Photo by Markus Winkler on Unsplash

GCN in brief

Back to the source

Netherlands | England’s Cass report shows the need for close scrutiny of the puberty blocker-driven Dutch protocol for paediatric gender change, according to an opinion article in the Netherlands newspaper NRC by journalist Jan Kuitenbrouwer and media sociologist Peter Vasterman. They write: “[After publication of the Cass report], all eyes were on the Amsterdam UMC gender clinic, the birthplace of this treatment. The research that cannot stand the test of criticism was conducted here. The only response issued by the clinic is baffling. AUMC simply disagrees with the fundamental scientific criticism and points to the several studies that have shown beneficial effects. Yes, these are precisely the studies that Cass notes are of insufficient quality… It is high time for an audit, not of the scientific evidence base—which is now available—but of the actual clinical practice. What are the decision-making processes in the consulting rooms, and which considerations are used to decide on treatment?” Earlier this year, the Dutch parliament passed two motions calling for a closer look at youth gender medicine in the country.

Precedent

America | A federal appeals court has became the first in the US to rule that state healthcare plans must pay for transgender surgeries, The Washington Post reports. “The decision came from a set of cases out of North Carolina and West Virginia, where state officials argued that their [restrictive] policies were based on cost concerns rather than bias,” The Post says. “The US Court of Appeals for the 4th Circuit rejected that argument, saying the plans were discriminating against trans people in need of treatment. Judge Roger L. Gregory, an appointee of President Bill Clinton, wrote for the majority that the restrictions were ‘obviously discriminatory’ based on both sex and gender.” In a dissenting opinion, Judge Jay Richardson, a Trump appointee, said it was not discriminatory for the states to exclude healthcare coverage according to diagnosis: “Thus, a person is not covered for certain medical services [such as surgery] if they are seeking that service as treatment for gender dysphoria. But if they are seeking the same service for a different, qualifying diagnosis, then North Carolina and West Virginia would cover it—regardless of that person’s sex or transgender status.” The Post said the conservative-led Supreme Court had been reluctant so far to take on cases involving trans rights.

Growth without accountability

Australia | An article in the journal Australasian Psychiatry by academic psychiatrist Andrew Amos has noted the rapid expansion of youth gender clinics in Australia without high-quality research, external scrutiny or regular reporting of data—apart from (sometimes incomplete) responses to Freedom of Information requests. Dr Amos argues that, at the very least, public gender clinics should report “the number of new referrals and ongoing patients, relevant clinical characteristics such as natal sex and gender identity, and number of newly initiated and ongoing treatments by type.” Citing potential legal liability issues following England’s Cass report, Dr Amos says it would be “prudent” for Australia’s health authorities to acknowledge the uncertainties of the “gender-affirming” treatment model and to engage with critical voices.

Pushback

Germany | A draft treatment guideline for gender-distressed minors—to be used in Austria, Germany and Switzerland—has come under heavy criticism from a group of 15 child and adolescent psychiatrists with posts at German universities, the newspaper Die Welt reports. The gender-affirming guideline takes a liberal position on the use of puberty blockers, cross-sex hormones and surgery. The document—developed under the auspices of the German Society for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy (DGKJP)—dismisses compulsory psychotherapy before gender change as “unethical and obsolete”. A 100-page critique from the group of 15 psychiatrists warns against the new guideline normalising “potentially irreversible biomedical measures in physically healthy minors”. A co-author of the critique, Tobias Banaschewski of the Central Institute of Mental Health in Mannheim, told Die Welt: “It is almost absurd to dismiss psychotherapy as conversion therapy and to rely on medication and surgery, despite the fact that] there is insufficient scientific evidence that minors are clearly better off in the long term after a medical transition than before.” Parent groups have also cited potential conflicts of interest in the guideline project. “For example, one of the endocrinologists involved holds an endowed professorship at the Ruhr University Bochum, which is financed by the pharmaceutical company Ferring. Among other things, this company produces the GnRH agonist triptorelin, a substance that can also be used as a puberty blocker,” Die Welt reports.

Treatment without evidence

Europe | The medical news magazine Medscape puts the Cass report in the context of a broader European “move away from medicalised care to placing more emphasis on providing psychosocial support for [minors]”. The Finnish psychiatrist and researcher Professor Riittakerttu Kaltiala is quoted as hoping the Cass review will exert influence throughout Europe and elsewhere. Alexander Korte, a child and adolescent psychiatrist at Ludwig Maximilian University of Munich, describes the situation in Germany as “still very confused” with draft “trans-affirmative” treatment guidelines emerging at the same time as attention is called to “the lack of scientific evidence for the early medical intervention” of puberty suppression. Professor Korte said promotion of this intervention was “irresponsible because of the unclear data situation. If opposite-sex hormones are used after the puberty blockers, which is known to be the case in over 95 per cent of children treated with [these hormone suppression drugs], this leads to permanent infertility in addition to permanent impairment of the ability to experience sexuality.”

Caution is contagious

Belgium | A signed editorial in the Belgian Journal of Medicine and Healthcare argues that Belgium should follow the cautious example of Sweden and Finland, such that hormonal interventions for gender-distressed minors would become treatments of last resort. “For late-onset gender dysphoria, a psychotherapeutic course with a psychotherapist independent of a gender clinic is preferable,” says the editorial written by Patrik Vankrunkelsven of the Belgian Centre for Evidence-Based Medicine, Kristina Casteels of the Leuven University Hospital Paediatrics Department and Jens De Vleminck of the Child and Adolescent Psychiatry Service, KU Leuven. They note the exponential surge in young people seeking gender medicalisation and the puzzling shift in patient profile. “With the sharp increase in the number of patients in medical transition and the change in the population, concerns about the scientific foundation of the ‘Dutch protocol’ have also grown,” they write. “Against the mostly hypothetical benefits, which have largely not been empirically confirmed, there are significant risks associated with the use of puberty inhibitors: infertility, lifelong dependence on drugs, reduced bone density, reduced sexual functioning, more difficult genital surgery due to underdeveloped genitalia and suffering due to feelings of regret. In summary, we believe the situation is critical: an exponentially growing number of minors are considering a medical transition without good grounds to say that it will make their lives better.”