Shot in the dark

Unexpected doubt about gender medicine in Germany emerges from an official source

Photo by Aleksandr Popov on Unsplash

It cannot be ruled out that puberty blocker drugs do lasting damage to the cognitive development of minors, including the mental, emotional and behavioural aspects of their sexual formation, according to a research report from Germany’s parliament.

The report from the Bundestag’s Scientific Services, a research department with a brief to inform Germany’s politicians, is significant because the gender medicine debate in the country is dominated by uncritical support for these life-altering hormonal and surgical interventions as “human rights”.

The Bundestag report documents the trend in Sweden and other progressive Nordic countries to shift treatment policy away from the internationally imitated Dutch protocol of medicalised gender change for minors who identify as transgender or non-binary; the report also covers the laws restricting paediatric transition in more than 20 Republican-run states in America.

“More and more countries have distanced themselves from this [Dutch] protocol in recent years, as doubts have arisen about its scientific validity due to various cases of significant long-term side effects, the lack of representative research results and concerns about the selection of test subjects,” the report says.

“The use of puberty blockers is currently the subject of controversial debate worldwide.”

Although the Bundestag report—titled “Legal bans on puberty blockers abroad”—suggests puberty blockers may be reversible when taken for “a number of years”, it cites a lack of adequate, evidence-based research in this field.

“It cannot be ruled out, for example, that puberty-suppression therapy could lead to a lasting impairment of psychosexual or psychosocial-cognitive development. Complete reversibility has also not been adequately proven. Overall, the exact extent of the side effects is still unclear.”

The report to Germany’s lawmakers also cites the scandal at the London-based Tavistock gender clinic, England’s proposal to all but end routine treatment with puberty blockers, the call for “great medical caution” by the French National Academy of Medicine, and the concerns of child and adolescent psychiatrists in Australia and New Zealand about the weak evidence base for paediatric transition.

Gender ideology is strong among German’s political, institutional and media elites. The Bundestag report is something of a counterpoint to campaigns for easy self-declared gender change (known as self-ID) in official documents, for a new medical guideline likely to liberalise access to paediatric transition, and for a scheme to underwrite gender medicine for adults and minors with government-subsidised social health insurance funds.

“It is well known that adolescence is a phase of reorientation and partial reinvention, for which the term ‘second psychic birth’ has characteristically been coined. Neuroscience has used imaging techniques to show that puberty is a phase of considerable remodelling and reorganisation of the maturing brain. Consequently, a permanent gender identity transposition of the transsexual type, i.e. the most severe form of gender dysphoria with a permanently fixed transsexual identity, can only be reliably diagnosed after puberty has ended. In other words, most adolescents are still in the middle of the process of finding their identity at this stage, and the latter is the result of successful development during puberty, not its starting point!”—Psychiatrist and gender dysphoria clinician Dr Alexander Korte, statement intended for the Bundestag; he was invited by a parliamentary committee to give expert evidence on the self-ID bill on November 28, then uninvited.

Law as a driver of treatment

Although Germany’s government—known as the “Traffic light coalition” because it combines the (red) Social Democrats, the (yellow) Free Democratic Party and the Greens—and its allies among the LGBTQ lobbies have presented self-ID gender change and the updated medical guideline for minors as quite unrelated, the Bundestag report notes media coverage quoting health professionals to the contrary.

“Doctors and psychologists are of the opinion that the desire for physical reassignment will also increase as a result of the lowering of the legal threshold [for gender change in documents],” the report says.

Under the draft self-ID law, minors from the age of 14 would be allowed to change their legal sex in the official registry with parental approval. A court would be able to override parental refusal, raising the stakes in family conflict over social and medical gender change. (The draft law is expected to have its second reading and a vote early in 2024.)

Child and adolescent psychiatrist Dr Alexander Korte of Munich’s Ludwig-Maximilian University, who is reportedly a lone voice for caution on the health professional commission crafting the new medical guideline for minors, has argued that the social transition enabled by the self-ID law will “drive up” the rate of children who persist in the distressing condition of gender dysphoria, thereby making lifelong medicalisation more likely.

He speaks with the experience of having treated adolescents with gender dysphoria since 2004.

He said puberty blockers were being promoted by their advocates as “medically harmless and ethically unproblematic” but has warned that suppression of natural sex hormones denies children “experiences necessary for the formation of their identity, including socio-sexual formation—that is, relationships.”

“These are necessary experiences also for a homosexual ‘coming out’.”

Trans on a roll

Against this background, Dr Korte has welcomed the Bundestag research paper as “enormously helpful” at a time when the draft medical guidelines for minors are heading in “a decidedly trans-affirmative” direction under the commission’s media-savvy chairman Professor Georg Romer.

The German Society for Child and Adolescent Psychiatry and Psychotherapy has reportedly backed Professor Romer and endorsed the incautious guidelines, with publication planned in the first quarter of 2024.

The Bundestag paper—and the mystery of who commissioned it—appear not to have been picked up by Germany’s mainstream media, where scepticism about the trans project is muted.

David Allison, a former Greens member and parent troubled about “the denial of reality in transgender ideology”, is the public face of a small lobbying group called Transteens Sorge berechtigt, a reference to the rights and duties of a parent amid the teenage turmoil of trans.

Mr Allison, English-born and with three decades’ living in Germany, said the Bundestag report, which cited the work of Transteens Sorge berechtigt, was noteworthy for acknowledging some doubt about gender medicine.

“It’s unusual, because you don’t hear this at all from the government side,” he said.

“The government appears to be really 100 per cent-captured by the trans activist side. Germany is the most extreme country in Europe about [gender ideology], I’d say.”

Philosopher Uwe Steinhoff of the University of Hong Kong, who has collaborated with Dr Korte in defending biological reality from activist misinformation, said the Bundestag report had its shortcomings but nonetheless its survey of countries retreating from paediatric transition was quite telling in the German context.

“The report flat-out contradicts a lie constantly told by influential ‘queer-political’ German government officials and sundry lobby groups indirectly financed by the government—namely, that ‘gender-affirmative’ care is state of the art when it comes to the treatment of gender dysphoria,” he said.

In fact, Professor Steinhoff told GCN, the gender-affirming approach built on the Dutch protocol of puberty blockers followed by cross-sex hormones and surgery was “outdated and being overhauled”.

“Bringing this to light in an official source, is what makes the report important for the public—and embarrassing for the dangerous German aficionados of ‘transition’.”

Several sources have noted some misfires in the Bundestag report, which—

Does not articulate the importance of systematic reviews of the evidence base undertaken in Europe;

Fails to show a command of the primary scientific literature;

Cites the “time to think” rationale for puberty blockers, but does not mention data showing that the vast majority of children begun on blockers go on to cross-sex hormones, which are supposed to be taken for the rest of their lives;

Attributes to blockers one of the known side effects of hormones.

“There is a well-founded suspicion that gender dysphoria, which those affected would have overcome naturally, is being forced iatrogenically [meaning it is a medicine-inflicted illness]. This is problematic because if the desire to transition persists, a young, healthy person will usually undergo lifelong hormone replacement and gender reassignment surgery with serious consequences for the body, such as permanent infertility. The administration of puberty blockers, opposite-sex hormones and similar preparations to a child who is unable to give consent therefore raises considerable ethical problems.”—From a 2022 Bundestag motion, put by the populist-right party Alternative for Germany, seeking a ban on paediatric transition and thorough research into the phenomenon.

Nothing to see here?

“A key strategy here in Germany,” Mr Allison says, “is constantly to suggest that practically no minors undergo medical or surgical treatment. But this is not the case. There are hospitals in Germany openly advertising mastectomies for minors.”

As for puberty blockers, the Bundestag report says they “may only be prescribed after careful medical indication on the basis of scientific guidelines.” Pending an updated guideline for minors, the prescribing of blockers in Germany is supposed to be in line with standards of care issued by the World Professional Association for Transgender Health (WPATH).

WPATH is not synonymous with caution—at best, its treatment guideline sends mixed signals—but Mr Allison says Germany’s trans establishment wants a more permissive regimen.

Unlike a centralised system such as the United Kingdom’s National Health Service, Germany’s is to some degree devolved to the federation’s states, with health professional bodies exercising considerable autonomy, as do social health insurance funds.

“The question about whether minors are allowed to have treatment at all—the government kind of refuses to take any responsibility for that, and just points to the professional bodies,” Mr Allison says.

For all the vagaries of the German health system, medical treatment of a minor does require parental consent—for now.

“But the trans activists want to eliminate parental consent,” Mr Allison says.

He believes self-ID alone could make it harder for parents to hold the line against invasive gender medicine.

“If, hypothetically, a 14-year-old girl goes to the registry office and gets her status changed to that of a boy, legally, it’s going to be very difficult for the parents to argue against medicalisation,” Mr Allison says. And he believes health professionals will be emboldened to push ahead with hormonal and surgical interventions.

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Self-ID: Tessa Ganserer, a transgender-identifying male who is a Greens member of Germany’s parliament, has been a controversial figure

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Power of the purse

Since May, Mr Allison has taken part in consultation workshops for the Ministry of Health, rubbing shoulders with trans activists and health clinicians. At issue is the federal government’s power as a paymaster—should there be legislation to require social health insurance to pick up the tab for hormonal drugs and trans surgery?

“The underlying philosophical problem is that there’s this attempt to depathologise the trans experience,” Mr Allison says. “But if you do that, it’s quite difficult then to argue that comprehensive medical procedures should be paid for out of the public purse.

“So, [the activists are] looking for ways to get around this.”

One possibility under consideration, he says, is to try to nudge trans medicine into the same category as pregnancy, fertility or contraception—“where you’re not ill, but you still get medical treatment.”

Statistics on paediatric gender medicine in Germany are limited. Some data does not separate minors from young adults.

In national data reported by the Bundestag’s Scientific Services, the number of genital surgeries in the 15-25 age group rose almost 1,600 per cent from 54 in 2007 to 917 in 2021.

The number of newly started puberty blocker treatments more than doubled between 2014 and 2019 from around 125 cases to around 275 cases, according to an extrapolation of data from the insurer Barmer. (Thanks to Madeleine for this data.)

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Chart: The trend in German minors covered by Barmer insurance and diagnosed with ‘gender identity disorder’

The vertical axis shows the number of patients under age 18.

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Off-the-shelf identity

In the German-language Journal of Child and Adolescent Psychiatry and Psychotherapy earlier this year, Dr Korte and co-author Dr Volker Tschuschke (former chair in medical psychology at Albertus Magnus University) published a paper with the title “Media’s Stranglehold on Storm and Stress: The Sorrows of Generation Z about Sex and Gender.”

The authors suggest that, like TikTok tics and Tourette syndrome, the distressing idea of young people feeling “born in the wrong body” is spread by social and mainstream media.

“ ‘Trans’ evidently represents a new off-the-shelf identity that is circulated via the mass media and that speaks to a group of vulnerable young people who have problems with self-perception, body acceptance and the integration of puberty-related maturation processes,” they say.

“Buffeted by contradictory social demands, unrealistic beauty ideals, typical adolescent insecurities, crises of shame and the search for meaning, these categorisations [of teenagers as trans or non-binary] allow young people to express their personal suffering in a form acceptable for their time and culture. They also promise attention, special status and the allure of the extraordinary.

“[However,] somatically healthy adolescents with functioning sexual organs and a normal hormonal profile who seek ‘gender transition’ are experiencing psychological confusion or going through a maturational crisis and are therefore suffering from a temporary disorder.”

In this context, the authors highlight the risks of Germany’s self-ID law enabling troubled teenagers to lock-in legally and socially a trans or non-binary identity, making it more difficult to grow out of this distress and confusion.

They ask whether “waving through a change of sex record as a purely administrative procedure will close off alternative options for the child such that they persist in their transgender identity.”

“Again and again, there is talk of the necessity for unquestioned ‘gender transition’ if someone is ‘in the wrong body’. But is there not an argument for describing this condition as a ‘false psyche’, a ‘false life’, a ‘false self’—in the ‘right body’?

“From the perspective of developmental psychology, it is absurd to assume that anyone is born with a pre-formed identity.

“The sense of belonging to one’s gender that is constituted in the course of psychosexual development from infancy onwards is consolidated and individualised, especially in adolescence, as the young person grows older, as sexuality emerges and first socio-sexual contacts take place.”

“Rap songs, violent horror films or bloody video games: In Germany, content that is harmful to minors ends up on the [censureship] index. Now the Federal Centre for the Protection of Children and Young Persons in the Media has indexed a trans guidebook that aims to protect children from gender reassignment. The authority is subordinate to the Ministry of Family Affairs headed by Lisa Paus (Green Party). [It] shows how arbitrarily censorship is carried out in the name of the rainbow flag: while ‘trans children’ are injected with puberty blockers in ARD and ZDF [public broadcast] programmes, the work of women who are critical of the trans trend is suppressed with state support.”—Journalist Judith Sevinç Basad, news report, NiUS.de, 17 September 2023

“Germany’s public broadcasters are pumping out unscientific messages about biological sex likely to confuse children and promote transgender medicalisation, according to an open letter campaign launched by 120 scientists, psychologists and educators.”—news report, GCN, 29 June 2022

Teens in the now

In their paper, Drs Korte and Tschuschke argue that children and adolescents are not equipped to consider the long-term prospects for someone who embarks upon a medicalised gender change.

“Young people typically disregard the lifelong consequences of physical-medical transition treatment,” the authors say.

“Surgical ‘gender reassignment’ inevitably involves mutilation of the body. Thus, in addition to the loss of fertility, the anatomical prerequisites for sexual arousal and satisfaction are functionally damaged, or at least impaired, if not destroyed.

“The few serious follow-up studies that cover a sufficiently long period of time and that draw on the most objective data available, conclude that ‘sex-reassignment surgery’ confers no psychological benefits.

“On average, people do not have fewer doctors’ appointments, fewer hospitalisations, fewer anxiety disorders or suicide attempts. On the contrary, nota bene, they experience more of these than before their ‘gender reassignment’! [These patients] remain a risk group after medical transition and require psychotherapeutic support for a very long time.”

The authors characterise the dominant approach in Germany today as one that “does not critically question the trans identification at all and that in the case of children or young adolescents more or less automatically leads to puberty-blocking treatment”.

By contrast, their paper advocates for “an open-ended, gender-critical intensive psychotherapy which retains the possibility of resolving gender dysphoria.”

“We are fundamentally skeptical of any approach that anticipates complete salvation and relief from psychological suffering through aesthetic surgical procedures. Hormone treatment and surgical interventions on the healthy body can at best offer some alleviation, and are only then ethically justifiable in the very rare cases of [enduring] gender dysphoria of the transsexual type.”

And the authors suggest that aggressive trans activism has frustrated the debate necessary to arrive at the best therapeutic response to a fast-growing group of vulnerable young people.

“In a democracy —and especially in a scientific controversy—it must be possible to take cognizance of the facts and engage in fact-based debate instead of adopting the recommendations of radical activists, muzzling all differences of opinion, criticism of any kind and thus every discussion by means of personal accusations, denunciations, systematic cancellations or even threats—and in this way refusing to engage in discourse,” they say.

“Factual, scientifically supported arguments against setting young people on a pathway to ‘gender reassignment’ treatment, the first step of which involves puberty suppression, should be taken seriously.”

Note: The LSVD, a major German LGBT lobby, makes the case for self-ID here, while the Federal Ministry for Family Affairs, Senior Citizens, Women and Youth promotes ‘gender-affirming’ medical interventions on its Rainbow Portal.