Medical care for children and adolescents with gender dysphoria and gender inconsistency in the light of current recommendations - how to implement the "primum non nocere" principle?

Abstract

Gender identity is one of the essential aspects of human functioning. The diagnosis of gender dysphoria or gender incongruence applies to people who do not have any developmental defects of the genital organs or sex hormone secretion disorders, while the problem is the lack of acceptance of functioning in their own body and the desire to become a person of the opposite sex. This phenomenon is increasingly observed in children and adolescents. In recent years there has been a trend towards earlier use of puberty blockers and sex steroids in minors with gender dysphoria or gender inconsistency in order to inhibit the development of sexual characteristics in the direction of their own sex (referred to as the sex assigned at birth) and to mimic them to the opposite sex, i.e. according to their gender identification. In addition, surgical procedures are performed to remove the gonads and change the appearance of the genitals (and/or breast) in the desired direction (these procedures are allowed in adults, although there are many advocates of performing them in adolescents). Such therapies have been described as "gender-affirming", as opposed to "conversion" therapies, i.e. interventions aimed at restoring the acceptance of one's own sex. The literature emphasizes the lack of evidence regarding the effectiveness and safety of these procedures, allowing for an unequivocal recommendation of their application in children and adolescents, as well as the possible relationship between the increase in the frequency of gender identity disorders and the influence of peer groups, in particular the media creating a climate of affirmation of transsexualism (and non-binary gender identification). Therefore some countries (e.g. Sweden) have tightened their legal regulations in this area. The most serious long-term consequence of gender-affirming therapies is infertility. This paper aims to present these problems based on current medical literature. Extremely important bioethical and legal aspect of these issues will only be indicated, although they undoubtedly require special attention and separate studies.