Hormonal Tx of Youth With Gender Dysphoria Stops in Sweden

May 12, 2021

Karolinska Hospital in Sweden, plus a number of the other centers in the country that treat youth with gender dysphoria, has become the latest clinic to stop the routine hormonal treatment of youth under 18.  

The new policy, affecting Karolinska's pediatric gender services at Astrid Lindgren Children's Hospital (ALB), in Stockholm, has ended the practice of prescribing puberty blockers and cross-sex hormones to minors with gender dysphoria.

Hormonal treatments will now only be prescribed to patients under the age of 18, and treatment may only occur within the setting of a clinical trial approved by the EPM (Ethical Review Agency/Swedish Institutional Review Board).

Other centers in Sweden that treat gender dysphoria youth — in Lund and Linköping — will follow the lead of the ALB. Other centers in Umeȧ, Alingsȧs in Gothenburg, and a center in Uppsala have not yet decided whether they will do the same, Olle Söder, MD, PhD, a pediatric endocrinologist who retired from Karolinska Hospital 2 years ago, told Medscape Medical News.

This decision comes amid growing unease in some quarters regarding the speed at which hormonal treatment of children with gender dysphoria has become accepted as the norm in many countries, despite what critics say is a lack of evidence of any benefit, plus known harms, of treatment.

The Swedish hospital cited the Keira Bell ruling in the UK as having an impact on its decision. As detailed in a recent Medscape Medical News feature, the December 2020 ruling by the High Court in London effectively stopped the initiation of puberty blockers in children under 16 with gender dysphoria, and recommended that those between the ages of 16-18 seek court approval for any hormonal treatment.

"The UK ruling, from an endocrinology point of view, is that these interventions are experimental, that young people can't understand the implications of initiating puberty blockers, cross-sex hormones, and surgeries — and that makes sense based on our understanding of brain development, endocrinologist Will Malone, MD, of Twin Falls, Idaho, told Medscape Medical News when interviewed for the feature.

Malone is one of several clinicians and researchers who formed the Society for Evidence-Based Gender Medicine (SEGM), a not-for-profit organization that now has at least 100 physician members, and which calls into question the medical transition of youth with gender dysphoria.

In a statement on its website, following the Swedish announcement, SEGM said: "This is a watershed moment, with one of world's most renowned hospitals calling the 'Dutch Protocol' experimental and discontinuing its routine use outside of research settings."

A number of US states are also attempting to outlaw the medical, and surgical, treatment of youth with gender dysphoria under 18; the first being Arkansas which passed such a law last month which — if not overturned — will come into effect in July. The bill bans doctors from prescribing puberty blockers, hormone therapies, or genital-altering surgeries for anyone under 18. Even referring a youth for such treatment from another doctor is prohibited.

The Endocrine Society has condemned such laws, and in June it will join in and appear against the UK High Court ruling in the Keira Bell case.

"The treatment of transgender and gender diverse youth should be governed by the best available medical evidence, not politics," said Joshua D. Safer, MD, coauthor of the Society's Clinical Practice Guideline and position statement on transgender medicine. 

Sweden is continuing to fully review its guidance on the issue.

In December 2019, its SBU (Swedish Agency for Health Technology Assessment and Assessment of Social Services) published an overview of the knowledge base, which was partly instigated by a three-part Swedish documentary entitled, "Trans Train." This chronicled several interviews with detransitioners — individuals who medically transitioned to the opposite gender, and in most cases had surgery too, but who came to regret the decision — and stated that medical transition of minors is not evidence-based. 

The final guidelines will appear in print and online at the beginning of 2022, Söder told Medscape Medical News.

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