LAUSR

Providing care to transgender people is a complex task, and treatment options should be tailored to each individual. Preliminary research suggests that gender affirmation can improve the mental health and quality of life of transgender people, both directly (through the effect of affirmation on wellbeing) and indirectly (through reduced exposure to minority stressors such as discrimination and violence). There are multiple domains of gender affirmation for transgender people: social (changing name and pronouns), legal (changing gender on official documents), medical (including hormonal therapy) and/or surgical affirmation (including mastectomy, vaginoplasty, orchidectomy and so on). The access to the different domains of gender affirmation differs widely among countries, leading to huge inequalities (table 1). Just a few miles can dramatically change the present (as they might not have access to specific or appropriate care during childhood and adolescence) and the future (lacking the perspective of a fulfilled life in adulthood) of young people with gender dysphoria. In Europe, for instance, there are ‘multiple speeds’ in transgender rights: while some nations are pushing forward (legal gender change, optional surgical intervention, hormonal treatment before the age of 18), others are going back (questioning or revoking the right to access genderaffirmation procedures). Young transgender people continue to face disparities in access to care, both as availability of specialised paediatric services (eg, in England, there is a single English service, based in London and Leeds, while in Spain, there are more than ten centres for a smaller population) and as the quality of psychological and medical care (with ‘nonofficial pseudounits’ that recently flourished in both the public and private healthcare sectors). Furthermore, only a few countries—the first being Malta since 2016—prohibit conversion or reparative therapies, a discredited collection of pseudoscientific methods that aim to change a person’s gender identity. When it comes to medical affirmation, the most widely used protocol in adolescents is the 'Dutch protocol', now also used in other countries in Europe, such as Italy. It consists of puberty blockers at age 12 (or on reaching Tanner stage 2 of puberty) and genderaffirming hormones when they reach the age of 16. The effectiveness of this model has been shown as those subjects who underwent puberty suppression had fewer behavioural and emotional problems as well as depressive symptoms. The minimum age to access genderaffirming hormone therapy without consent of a public authority and/ or parents, however, varies throughout countries ranging from 16 to 18 years, while it may be lower in case of parental consent (eg, 12 years in the Netherlands). Even though the Dutch protocol seemed to be gaining momentum, several positions opposing this approach have been reported in the last year, as legislation criminalising the provision of genderaffirming care is on the rise. In the UK, a High Court decision in December 2020 stated that puberty blockers should not be administered to children under 16s—unless a court has ruled that it is in their best interest. They claimed that it was not clear whether children under the age of 16 could provide informed consent to treatment with hormone blockers. In April 2021, Arkansas passed Act 626 (‘Save Adolescents From Experimentation’), becoming the first US state to pass a bill restricting access to genderaffirming healthcare for anyone under 18 (including puberty blockers and hormone therapy). Even those undergoing treatment at the time of the ban and those who have parental consent cannot access the hormonal treatment. Mr Backholm opened his speech favouring the Arkansas bill by defining transgender identity as a ‘cultural phenomenon’ of 21stcentury teenagers. However, recent evidence showed that the increase in the incidence of gender dysphoria is actually due to less stigma and better tools to recognise it (as it happened for attention deficit hyperactivity disorder or autistic spectrum disorder, which have both dramatically increased in the last years). What was observed in previous years was probably just the tip of an iceberg that has come to the surface in recent years: as a matter of fact, there were no critical changes in key demographic, psychological and treatment characteristics over 16 years. Although both decisions have been eventually overturned, the net result was a limitation for children and adolescents to access treatment. This had a significant impact on the mental health of young people with gender dysphoria for those forced to stop puberty blockers and for those eligible for pubertal suppression that could not receive it. On the legal side, gender recognition procedures have been associated with lower reports of upsetting responses to genderbased mistreatment and lower reports of depression, anxiety, somatisation, psychiatric distress. Before 18 years, legal gender recognition procedures are allowed only in some countries, usually requiring parents' consent. While in some countries (such as Norway), adolescents can change their legal gender on their own after the age of 16, in others (such as Italy), a Court decision or additional conditions are needed. For instance, the approval of an interdisciplinary committee in Greece or a paediatrician in Croatia is required. Some countries (such as France or Finland) only allow name changes in minors. On the one hand, transgender people are still not allowed to legally change their gender—not even as adults—in several European countries, including Bulgaria and Hungary. For example, Hungary never had a detailed legal background for transgender people, and it has never been clear who can request gender affirmation. Nonetheless, people have had the chance to change their names and gender in their official documents since 2000. However, recently the right to legally change the gender on official documents has been revoked. On the other hand, there has been a clear shift in a part of Europe (the first country being Estonia since 2002) to push back the legitimacy of involuntary surgery and sterilisation to be formally acknowledged in the preferred gender. These requirements are derived from an incorrect assumption that physical changes are essential for Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, Limburg, The Netherlands IRCCS Materno Infantile Burlo Garofolo, Trieste, FriuliVenezia Giulia, Italy