Gender reversal
France thinks twice about demand-driven transition for teenagers
French health authorities have abandoned draft treatment advice that would have treated 16- and 17-year-olds as if they were adults and enabled their fast-track gender medicalisation under the banner of “depathologisation”.
On July 18, the French National Authority for Health (La Haute Autorité de Santé, HAS) issued a charter for the unquestioning medical transition of adults throughout primary care, but chose not to issue advice for the teenage group, citing a lack of data and consensus on the care of gender-distressed minors.
The decision is significant because it is the first official pronouncement in the era of “gender-affirming care”—and the first sign of caution—from the French agency that shapes national health policy.
Mainstream concern about paediatric medical transition in France has been building for some years, with the National Academy of Medicine issuing a statement in February 2022 urging “great medical caution” and the prioritising of “psychological support” rather than risky, irreversible treatment for minors.1
Last December, the newspaper Figaro obtained a copy of the HAS draft advice under which 16- and 17-year-olds would have quasi-adult access to cross-sex hormones and transgender surgery. The advice made provision for the authority of parents resisting medical interventions to be set aside. The HAS working group responsible was stacked with trans activists and gender-affirming practitioners, according to Figaro.
It seems the working group did achieve consensus on teenage treatment, but on Friday this was negated by the HAS citing “the absence of sufficiently robust data and consensus” on the care of minors.
The decision to change course—and to reconsider the care of 16-17-year-olds as part of a new HAS working group process on treatment advice for minors generally—has dismayed the affirmative lobbyists and delivered their critics at least a reprieve.
“This withdrawal [of the draft advice] confirms what many professionals have been saying for years: the medical practices currently offered to gender-questioning minors are based on fragile or even non-existent scientific evidence,” said the watchdog group The Little Mermaid, which brings together medical doctors, psychologists, lawyers, psychoanalysts and teachers concerned about ideological risks to childhood development.
“The HAS now recognises that the quality of the available evidence is open to debate and controversy. This admission is all the more important given that the subject concerns children.”
The group Lawyers for Children said: “The HAS seems to have realised that administering hormones and performing surgery with irreversible consequences in order to give a body the appearance of the opposite sex is the subject of fierce medical controversy and that minors are not in a position to give consent to such serious acts.”
However, quite apart from the formal position of the HAS, current practice with minors seeking transition lacks caution, according to clinical psychologist Céline Masson, co-president of The Little Mermaid.
“Transgender services and consultations listen to minors’ requests and support them without questioning them,” Dr Masson told Figaro.
Almost adult
The HAS was given the task of updating its 2009 adult guideline on “Medical care for transsexualism” by the then Health Minister Olivier Véran in 2021, the same year in which The Little Mermaid group embarked upon its mission to scrutinise the trend of paediatric trans identity and medicalisation.
Minors from the age of 16 were reportedly included in the minister’s referral on the basis that they were close to adulthood; these teenagers were to be the subject of a specific chapter written by the HAS working group.
In coverage by the newspaper Le Monde, working group member Jean Chambry, a child psychiatrist and gender clinician, said the HAS decision not to publish the teenage guidance was disappointing “because it is minors who are at the centre of the public debate.”
In media reports elsewhere, Dr Chambry said the final recommendations for adolescents were “more nuanced” than those revealed by Figaro last year.
And he said the working group’s adolescent chapter “wasn’t approved because there weren’t enough studies, but that’s debatable.”
“However, what is still very surprising in our society is that we say that from the age of 16, we are too young to know our gender, but all the reforms to the juvenile justice system are moving in the direction of holding us responsible for our actions at that age,” he said.
Dr Chambry also defended hormone treatment as “partially reversible” and claimed the treatment regret rate was “very low, around 1-3 per cent”. There is reason to suspect a markedly higher rate among today’s teenage gender clinic caseloads, but the true scale of detransition is not yet clear.
The July 18 HAS statement said very little about its change of position on minors, focusing instead on a nationwide “depathologised” treatment model for adults “wishing to embark on a transition process.”
“The aim is to promote the person’s autonomy in order to help them identify and make informed choices, in accordance with the principle of self-determination. It is essential to welcome the person without judgement or preconceived ideas about their gender identity and needs, in particular by using the first name and pronouns they request. Gender identity should not be the subject of a specific psychiatric assessment.
“The HAS recommends that general practitioners (le médecin généraliste) should be able to receive all requests for care and coordinate treatment throughout the process. They can monitor prescriptions and, if trained, prescribe gender-affirming hormone treatments for the first time.
“With regard to surgical care, the HAS recommends that requests for surgery from transgender people be met. It emphasises the need to provide clear, honest and appropriate preoperative information on surgical procedures, risks (short- and medium-term) and the irreversible nature of certain procedures for which a reflection period is provided, in order to enable the person to give their informed consent.”
Media coverage noted some signs of caution in the adult recommendations.
On July 18, Figaro reported that—
“Compared to the initial working document, however, the HAS has paved the way for precautionary measures to ensure that [adults] who initiate a gender transition request are fully aware of the consequences of the care they are requesting.
“Clinicians will be able to ‘impose a reasonable reflection period’ before any intervention, particularly when the effects are irreversible, such as certain hormone therapies or gender reassignment surgery.”
Le Monde said the HAS advice “does not shy away from the sensitive issue of ‘detransitioning’, even though ‘very little data’ exists on this subject, recommending that these patients be supported ‘in the same way’ as those requesting transition.”
Even so, HAS President Lionel Collet said the decision to embark on gender transition was personal—“it is not for us to comment on this decision,” and his agency saw the role of the health practitioner as being one of supporting adults as they transition.
Le Monde said there were no statistics available to estimate unmet demand.
“However, in 2023, the French health insurance system recorded just over 22,000 people receiving long-term care for a diagnosis of trans identity or gender dysphoria. In 2020, there were nearly 9,000—70 per cent of whom were between the ages of 18 and 35,” the newspaper said.
The demand-driven nature of the new HAS model, and its incuriosity about the reasons for gender distress, have aroused concern about the risks to young adults whose brains are not fully mature until their mid-20s.
The Ypomoni parents’ collective, which takes its name from the Greek word for “patience”, deplored a “lack of caution” for the 18-25 year-old group as hormones and surgery are to be “mainstreamed” in public health.
“The HAS proposes easier access to care for young adults, in line with the new recommendations from Nordic countries and the UK,” the collective told Figaro.
“No psychological assessment is mandatory … Transgenderism may not be considered an illness, but we must also recognise that it often affects young people who are not well, who are autistic or who have neuro-developmental disorders. Their transition should only take place in a hospital setting.”
The HAS process to develop treatment recommendations for minors generally—not just older teenagers—is to start next year with a new working group yet to be appointed.
Dr Masson of The Little Mermaid group told GCN she was confident that “the HAS will be cautious when it comes to children under 18.”
She said it was urgent to return to the fundamental question of diagnosis—“not all of these young people are ‘dysphoric’, or else this dysphoria masks psychological or psychiatric problems.”
The Little Mermaid has proposed a new clinical term “adolescent pubertal anxiety” (angoisse de sexuation pubertaire) to help explain the unprecedented international surge in young people rejecting their birth sex.
“[This term] offers a different way of understanding the physical and psychological suffering experienced during adolescence—and even up to the age of 25—that is often associated with requests for transition,” the group said.
The group promoted this clinical category with a poster at the recent International Congress of the European Society for Child and Adolescent Psychiatry in Strasbourg, France.
The academy, a non-government body, has moral but not legal authority, hence the importance of the more cautious position adopted by the HAS, which is a key public health institution.
. . . . It would be interesting to ponder the regret rate in the cohort referenced in this publication from JAMA in June 2023. titled:
‘Transgender Identity and Suicide Attempts and Mortality in Denmark’
Conclusions and Relevance:
In this Danish population-based, retrospective cohort study, results suggest that transgender individuals had significantly higher rates of suicide attempt, suicide mortality, suicide-unrelated mortality, and all-cause mortality compared with the non-transgender population.
"Dr Chambry also defended hormone treatment as “partially reversible” and claimed the treatment regret rate was “very low, around 1-3 per cent”."
Doesn't that 1-3 per cent come from something called the Bustos study? Jesse Singal analyzed it, I believe, and found that numbers were mistakenly doubled in the study leading to lower regret rates by around half.