Outlier

A new German treatment guideline spurns Europe's shift to caution on paediatric gender medicine

Photo by Norbu GYACHUNG on Unsplash

Germany’s new “affirmation-only” treatment guideline for the use of puberty blockers and cross-sex hormones goes beyond the weak evidence base, may lead to vulnerable young people suffering harm and should be withdrawn, according to prominent child and adolescent psychiatrist Professor Florian Zepf.

The new S2k German-language guideline—on Gender Incongruence and Gender Dysphoria in Childhood and Adolescence—was published earlier this month and is intended for use in Germany, Austria and Switzerland.

But Professor Zepf, who directs the Clinic of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy at Germany’s Jena University Hospital, believes many practitioners regard the guideline as “highly problematic” and will not adopt its treatment recommendations.

“It is still not too late to withdraw these guidelines and revise them in the light of actual medical evidence,” he writes in an opinion article for GCN.

“The responsibility for addressing these serious shortcomings and upholding the fundamental medical principle of ‘First, do no harm’ rests with those who developed and approved this very problematic guideline.”

Professor Zepf was a member of the guideline development group but left because of professional and ethical concerns.

The guideline process had been led since 2017 by the German Society for Child and Adolescent Psychiatry and Psychotherapy (DGKJP) but the project’s dogmatic “gender-affirming” direction and a 2024 draft document provoked criticism and dissent.

Since 2019, multiple systematic reviews of the evidence undertaken in Europe have challenged the confident promotion of puberty blockers and cross-sex hormones as a safe and effective response to gender distress in minors. As a result, Finland, Sweden and the UK have adopted more cautious, less medicalised treatment policies.

In response to last year’s draft for the S2k guideline, the 126th German Medical Assembly passed a resolution in which the German Medical Association called on the country’s federal government to restrict puberty blockers, cross-sex hormones and trans surgery for minors to ethically controlled clinical trials with at least ten years’ follow-up.

Such warnings appeared to have little influence on the guideline development group.

---

Video: Genspect’s Detrans Awareness Day, March 12, 2025, on Capitol Hill, Washington DC. Action starts at the 28 minute mark, main detransitioners’ panel from 1:15, names and other details here

“… the [S2k] guideline that has now been published, which has been developed since 2017 by a commission under the direction of the Münster psychiatrist Georg Romer on behalf of the German Society for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, is highly controversial. This is because the guideline developers have been committed to the gender-affirmative approach from the outset.”—Journalist Till Randolf Amelung, commentary, Queer Nations, 8 March 2025

No better now

Child and adolescent psychiatrist Dr Alexander Korte, a Munich-based gender dysphoria expert and critic of the gender-affirming treatment approach, said the final guideline was little changed from the flawed draft of 2024.

He said one addition—criticism of England’s 2020-24 Cass review—involved an absurd, almost incomprehensible attack on the competence of Dr Cass and her review’s independent researchers at the University of York.

The German guideline’s disapproval of the Cass review has been seized on by the American trans activist Erin Reed as if it represents a new contribution to the debate. However, the guideline does little more than recycle claims from the so-called Yale white paper, which was misleadingly promoted as if it had the imprimatur of that university. This paper was not peer reviewed, unlike published critiques of its errors and distortions.

By contrast, the German guideline gives a positive account of the gender-affirming treatment advice issued by the World Professional Association for Transgender Health (WPATH), the Endocrine Society and the American Academy of Pediatrics, without acknowledging the various scandals and critiques affecting their credibility.

Dr Korte, who is a board member of the German Society for Sexual Medicine and Sexual Psychology (DGSMP), said it remained the case that the new S2k guideline was ideological and “exclusively trans-affirmative” in its approach.¹

“The guideline recommendations are in no way evidence-based,” he told GCN. “Moreover, the guideline suffers from serious methodological deficiencies.”

“My professional association for sexology (DGSMSP) already declared at the beginning of 2024 that it would not endorse the guideline.”

Like Professor Zepf, Dr Korte removed himself from the guideline group.

Dr Korte said the serious concerns of the psychiatric profession were made clear by the dissenting opinions of the German Society for Psychiatry, Psychosomatics and Neurology (DGPPN) published with the finalised guideline.

“This guideline claims to set the medical standard in the field of treatment and is to be applied in Germany, Austria and Switzerland. However, it is questionable whether it will actually be widely applied, because an important professional association [DGPPN] refused to give its consent and demanded that its criticism be published as well.”—Journalist Till Randolf Amelung, commentary, Queer Nations, 8 March 2025

Slow down, think

German parents are wary of rushed medicalisation, according to a critique of the new guideline from David Allison of the group Transteens Sorge berechtigt, its name being a reference to the rights and duties of a parent amid the trans turmoil.

“[Parents] fear that their children’s self-diagnosis of trans will be confirmed too early and too quickly, that they will be unnecessarily medicalised, because they have completely different problems or, for example, are struggling with their sexuality or sexual orientation,” Mr Allison said on X/Twitter.

“A more cautious holistic non-invasive treatment, for example, through psychosocial, psychological and or psychiatric measures, such as those now offered as primary care in some European countries—which have turned away from the body medicine-oriented approaches à la WPATH—is hardly accessible to many gender dysphoric teens and twentysomethings in Germany, Austria and Switzerland, as it is offered almost nowhere when gender dysphoria is present.

“Unfortunately, the published guideline completely excludes this possibility [of a holistic and non-invasive response].

“The S2k guideline maintained its orientation toward the WPATH recommendations, even though WPATH has come under heavy criticism since 2024, and its recommendations themselves were not based on well-researched evidence and transparency or had been manipulated.

“WPATH has also demonstrably suppressed the publication of commissioned evidence reviews because the results apparently could not support the intended recommendations.”

The commentary from Transteens Sorge berechtigt argues that “gender dysphoria can be a symptom, an identification pattern and or a coping mechanism.”

“Parents are deeply afraid that their children will take the wrong path because affirmative therapists don’t even want to know what lies behind the symptom, the trans identity.”

“The exploration of other possible causes of gender dysphoria, in particular conflictual homosexual development, other puberty crises or accompanying conditions such as autism, is neglected —even worse: the German guideline gives the impression that this is ethically inappropriate. For this very reason, criticism has also grown among German medical professionals.”—Journalist Till Randolf Amelung, commentary, Queer Nations, 8 March 2025

Bad medicine makes bad law

In his article, Professor Zepf says open-minded psychotherapy should not be automatically opposed as unethical “conversion therapy,” and he warns that the misplaced confidence of the new guideline might lead to a court process in which cautious parents could lose custody of their children or control over medical decisions.

In one element of its detailed dissent, Germany’s psychiatric society DGPPN said the guideline should abandon its claim that, “There is some evidence from uncontrolled longitudinal studies that patients with persistent gender dysphoria diagnosed in adolescence who undergo a socially supported transition and receive staged body-modifying treatment show long-term improvement in quality of life and mental health in adulthood.”

DGPPN argued that such a statement of benefit was simply “not possible, based on the current evidence.”

“Decisions in favour of medical measures that intervene in an uncompleted biological development of maturity imply a particular challenge and ethical responsibility for all parties involved,” the society said.

It cited systematic reviews commissioned by Dr Cass and concluded, “There is a lack of high-quality research to evaluate the use of sex-modifying hormone treatment in adolescents with gender dysphoria/incongruence.”

1. S2k refers to the quality of the evidence for the gender dysphoria guideline developed under the umbrella of the Association of Scientific Medical Societies in Germany (AWMF). In his 2024 book Behind the Rainbow: An Evidence-Based Look at the Gender Debate and Gender Dysphoria of Minors, Dr Korte noted that this AWMF guideline project was initially registered as an S3 guideline, denoting a secure evidence base, notwithstanding the lack of a single randomised controlled study. Criticism on this point led to the guideline being downgraded to S2k, meaning a document reflecting a mere consensus of those developing the guideline. The gender dysphoria project included representatives of trans activist organisations.