May 10, 2024

The German Medical Assembly Passes a Resolution to Restrict Youth Gender Transitions to Controlled Research Settings

The future of youth gender transitions in Germany is now in question, as the resolution clashes with the trans-affirmative draft guidelines released in March 2024

Earlier this week, the 128th German Medical Assembly, which comprises 250 delegates from 17 German medical associations, passed two important resolutions: to restrict puberty blockers, cross-sex hormones, and surgeries for gender-dysphoric youth under age 18 to controlled clinical trials; and to restrict self-ID laws to those over age 18. 

The first resolution (Ic-48) focused on "gender-affirming care" for youth. The resolution, upvoted by the majority of physician delegates (120 votes in favor, 47 against, and 13 abstentions), stated: 

"The 128th German Medical Assembly 2024 calls on the Federal Government to only permit puberty blockers, sex-change hormone therapies or gender reassignment surgery in under 18-year-olds with gender incongruence (GI) or gender dysphoria (GD) in the context of controlled scientific studies and with the involvement of a multidisciplinary team and a clinical ethics committee and after medical and, in particular, psychiatric diagnosis and treatment of any mental disorders. The therapy results of any interventions of this kind must be followed up sociologically, medically, child and adolescent psychiatrically, socially and psychologically over a period of at least ten years and the evaluation results incorporated into the revision of the 'Guideline on gender incongruence and gender dysphoria in childhood and adolescence: diagnosis and treatment.' "

The resolution noted the profound life-long consequences of youth transitions (including the loss of reproductive function) and the absense of reliable evidence in the area of youth transitions. The authors also pointed out a key finding from a recent Dutch study on gender non-contentedness in youth, stating: "gender or sex dissatisfaction is most common at around the age of eleven, and the frequency of this symptomatology then decreases with age. The clear majority of minors show no persistent gender or sex dissatisfaction over the course of their lives."

The second resolution (Ic-128) (adopted with 110 votes in favor, 64 against and 14 abstentions) focused on the recent “self-ID” legislation. It stated that minors should not be allowed to "self-identify" into a chosen sex without a prior specialist child and adolescent psychiatric diagnosis and consultation. 

Both resolutions provided justification for the recommendations (see the German-language resolution and the English machine-translated versions attached below). 

These resolutions are at odds with the recently published trans-affirmative recommendations in the "Gender Incongruence and Gender Dysphoria in Childhood and Adolescence: Diagnosis and Treatment" 2024 guidelines. According to the draft guidelines, the only requirement for medical gender transition of youth is the provision of the adolescent diagnosis of "Gender Incongruence." The previously required "distress" criterion has been re-interpreted merely as "anticipatory anxiety" over developing secondary sexual characteristics and a desire to avoid future pubertal changes. Further, the current draft states that requiring psychotherapy as a prerequisite for gender-transitioning of minors is not ethical, and allows for the prescription of puberty blockers "provisionally" before a comprehensive evaluation takes place. 

The guidelines were developed under the umbrella of AWMF, the Association of Scientific Medical Societies in Germany. It was formally led by the German Society for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy (DGKJP), with 26 other medical organizations from Germany, Switzerland and Austria participating. The draft is scheduled to be voted on by the Boards for the 27 societies, and, if accepted, will be published in June 2024 as the final guideline.

SEGM Takeaway

The resolution cautioning against youth transitions in general medical practice has been passed by Bundesärztekammer, a self-governing body for physicians in Germany. The draft of the trans-affirmative guidelines has been published by AWMF, which is an umbrella organization for Scientific Medical Societies in Germany. Neither organization appears to have a binding authority. The fact that these two sets of recommendations have clashed suggests that Germany's federal government may have to intervene to reconcile the two conflicting directions.

Of note, AWMF states that "the primary aim of clinical practice guidelines is to enhance good clinical practice" by assessing "comprehensive knowledge (scientific evidence and clinical experience) about problems of care, to reconcile opposite views and to define current optimal practice by trading off benefits and harms." AWMF recognizes that "the effectiveness of guidelines depends on their acceptance and the reliability of their recommendations" (pp. 7-9). Even if the draft guidelines are accepted and published as final in June (as originally planned), the Bundesärztekammer resolution signals that the strongly "trans-affirmative" direction in the AWMF guidelines may not be viewed as credible by the future users of the guideline. 

SEGM plans to publish our analysis of the German guidelines' methodology and our assessment of their reliability in short order.