Trans youth, at the center of a culture war

In a short time, transsexuality has gone from being considered a disorder that must be stopped or reversed with conversion therapies, to the idea, shared by many parents and professionals, that body change must be facilitated on demand as soon as possible to avoid suffering and the social consequences of maladjustment.

It is estimated that in adolescents with poorly resolved gender dysphoria, the risk of suicide is doubled and many parents are terrified of the possibility.

But moving from one sex to another is never easy and it takes time.

When someone embarks on this path, it is because they do not feel well in the sex they were born with, but it is not certain that the place they are going to is more comfortable.

The starting point is known, but the arrival point is not.

In any case, it is always a very personal journey, sometimes painful,

The LGTBI movement has conquered the right to move from one sex to another without being stigmatized or labeled as sick, and that is a great advance.

But some hormonal treatments are started before puberty, which raises the question of what the support should be like to minimize the risk of rash decisions that they may later regret.

Many adolescents come to the gender identity units full of doubts, ready to be helped, but others come with the urgent need to change their body at any cost.

They believe that it is the only way out of the black hole in which they find themselves.

These adolescents have to fight against rejection and social stigma, but also against the enormous pressure of a binary culture that requires them to resemble the felt sex as much as possible,

Cristina Garaizabal, a clinical psychologist, began accompanying trans youth in the 1980s in Madrid and now assists them at the Barcelona City Council LGTBI center: “The more marked the sexual stereotypes are, the more discomfort there is.

All the pressure is focused on the body.

A total concordance between biology and roles is demanded, and an impossible body ideal is imposed for most people, much more so for trans adolescents, which becomes an inexhaustible source of discomfort.

Sabel Gabaldón, a psychiatrist at the Sant Joan de Déu Children's Hospital in Barcelona, ​​shares this diagnosis and adds that some trans groups contribute to this binary polarization: "Just as there is an accepted homonormativity, a transnormativity has been created that spreads the idea that if you you feel bad about your body,

“I have the strange feeling that my body has been stolen.

In fact, I feel like it's been taken away from all trans people in general."

Thus began Miquel Missé, sociologist and trans activist, a pioneering book that questioned this transnormativity and that has become a reference text.

He had written and militated against the pathologization of transsexuality and in 2018 he felt the need to share that reflection: he wanted to recover the body that he had hated so much.

He titled it

, critically emphasizing this last concept, because he considers that no one is born in the wrong body.

He argued that the error is not in the person, but in a story of transsexuality according to which the origin of discomfort lies in the body and the solution is to transform it.

That approach had robbed him and many others of the possibility of living his body in another way, of loving him, of accepting him.

The problem, for Missé, is not the girl with the penis or the boy who bleeds, but a binary culture that forces you to mutilate or change your body in order to be desirable to others.

“I wrote the book because I saw that there were problematic things and a great silence about them.

Now I think there are still problematic things, but a big noise about them.

His book has helped focus and clarify the process, but he is upset that the idea is now used by those who do not accept gender self-determination or by those who militate in transphobia.

"There is an indication of the trans experience as problematic, and the noise that is being generated does not help children and young people with gender dysphoria," she laments.

The noise has to do above all with the treatments, which in the case of children and adolescents are fundamentally psychological and hormonal.

They can start before puberty and have a strong impact on physical appearance, although they are generally reversible.

Surgical sex reassignment treatments, on the other hand, hardly are because they involve major surgeries such as vaginoplasty, in which the penis is removed and a functional vagina is built, or phalloplasty, in which a penis is created with tissue from other parts of the body.

The difficulty lies in the fact that they begin in a period of immaturity and often in people who may have other factors of discomfort that are confused with those of gender.

In any case, it is a phenomenon that is on the rise, which supposes an important social challenge.

Between 2016 and 2020, the Sant Joan de Déu unit treated between 30 and 40 new cases each year.

In 2021 there were already more than 100. Some arrive from the hospital's psychiatric unit, after a panic attack or a suicide attempt.

Similar increases have been observed throughout the network of gender identity units that have been deployed throughout Spain since the Hospital Carlos Haya in Malaga opened a pioneering service in 1999, which was followed by the Hospital Clinic in Barcelona in 2006 and the unit founded in 2007 by Antonio Becerra at the Ramón y Cajal Hospital, which is now the reference center for the Community of Madrid.

Becerra, already retired, explained to this newspaper that they have gone from 100 new cases in 2017 to more than 600 in 2019. In Catalonia,

In 2017, attention to gender identity was entrusted to Trànsit, an organization that emerged within the Catalan Health Service itself, coordinated by Rosa Almirall.

This network has served more than 5,000 people between adolescents and adults since 2012, and every week it receives about 20 new cases.

The question that everyone asks is what is the reason for this sudden increase that is leading to the saturation of the equipment.

From conservative media, the idea is paid that it obeys a fashion encouraged by

, an approach that Rosa Almirall flatly rejects.

“There is no way to turn someone into a trans person.

When the need for another identity arises, it is because the one assigned at birth is in question.

The gender police acts rather to drown out this questioning.

Nobody has eaten the brains of the parents who come with their children.

As health professionals, our mission is to listen and accompany.

Do you really think that we assume to accompany all these people by a militant attitude?

It is the logical result of greater flexibility in sexual orientation.

The barriers of heterosexual normativity have been broken and that is why different identities and different expressions of gender arise.

Greater freedom and social openness now allow the difficulties or experiences that adolescents have with their gender to be expressed openly, to which other personal sufferings are often superimposed.

Teenagers are now asking questions that previous generations did not and are more willing to transgress gender norms.

The result is greater sexual diversity and more parents raising children without such strict policing of roles.

Keira Bell speaks to journalists outside the courts in London, on December 1, 2020. FACUNDO ARRIZABALAGA (EFE)

Faced with the increase in children and young people who begin a transition, the ghost of regret has broken into many countries as a fear, but also as a throwing weapon in the cultural war around feminism,

culture and transsexuality.

A manifestation of this tension was the boycott carried out in Barcelona by a few dozen activists who tried to prevent the presentation of the book

, by José Errasti and Marino Pérez, considering it transphobic.

theories

in the construction of the gender identity of many young people.

Along the same lines as this book, the Amanda association (Association of Mothers of Adolescents and Girls with Accelerated Dysphoria) maintains that the increase in cases of rapid-onset gender dysphoria, especially among girls, is due to a phenomenon of "contagion". social” that must be stopped.

These mothers vehemently oppose the approval of the trans law that contemplates gender self-determination and that treatments can be started based on the request of adolescents.

The conflict begins to surface: the gender identity unit of the Ramón y Cajal Hospital has been denounced by Rosario T., who does not agree that her 16-year-old daughter, who wants to be a boy, receives hormonal treatment.

She considers that it must first be ruled out that her discomfort is due to a mental pathology since she has suffered depression,

and a suicide attempt.

The problem is to determine if these three conditions, which occur very frequently in young people with gender dysphoria, are a cause or a consequence.

In Spain, the 2002 Patient Autonomy Law establishes the age of majority to make health decisions, with some exceptions, from 16 years of age, but most gender identity units consider parental complicity essential .

The protocol applied by Trànsit, for example, requires that between the ages of 16 and 18 at least one of the parents be involved in the start of the treatment and, from the age of 18, it is considered recommendable.

Gender transitions are never a linear path.

The professionals who accompany them do not like to talk about regret to refer to the changes that occur in the process, and even less to see them as a failure.

They believe that traveling is an experience, a search, in which you can come and go.

"You never go back to the place you started from," says Cristina Garaizabal.

“The problem appears if you have made irreversible decisions to achieve the gender that you thought you wanted and then it turns out that it was not,” she maintains.

Known cases of regret are very few, but have generated much controversy.

One of the most notorious has been that of Keira Bell, who took the British public health service to court in which she was treated for not having informed her well and "not having further questioned her decision to transit".

Keira received puberty blockers and cross-hormonal treatment starting at age 16.

At 20 she underwent a double mastectomy, but later she regretted it and now lives as a woman.

In a first sentence, the Superior Court agreed with her and not only noted defects in informed consent, but also questioned whether minors under 16 were mature enough to consent.

Last September, however, the Court of Appeals annulled the sentence.

He considered that the court had overstepped its limits, which had put “patients, parents and doctors in a very difficult position”, and made it clear that “it is for the doctors and not for a court to decide on the competence of a minor to consent. ”.

But the consequences of the case had already crossed borders.

In reality, there is hardly any data on how many detransitions occur.

A longitudinal study conducted in Sweden found that of 767 trans people tested, only 2% expressed regret after gender-affirming surgery.

Other studies in Great Britain and the Netherlands have found rates of 0.47% and 1.9%, respectively.

"In our case, we move within very safe margins," says Marcela Mezzatesta, psychiatrist at the gender identity unit of the Sant Joan de Déu Children's Hospital in Barcelona.

Of the 286 minors cared for since the unit was created in 2016, there have only been three detransitions, and two of them did not imply a change of opinion about gender: a boy decided to stop taking hormones because he had already achieved the changes he wanted and no he wanted to take medication all his life;

In the aftermath of

Hilary Cass, former President of the Royal College of Paediatrics and Child Health, was commissioned by the UK's National Health Service in autumn 2020 to conduct an independent review of the care provided by gender dysphoria units in the UK. public health service, assigned to the Tavistock and Portman NHS Foundation Trust.

The preliminary report regrets "the lack of routine and consistent data collection" on the evolution of the cases;

criticizes that these units take the gender identity expressed by the child or adolescent as the starting point for starting hormonal treatments and recalls that the construction of gender identity is a process that can undergo changes well into their twenties.

The British Health Secretary, Sajid Javid, has just announced that he will grant new powers to the commission chaired by Dr. Cass so that it can review the evolution of treated children.

Some health professionals say they have felt pressured “to adopt an unconditional affirmative approach”, while others believe that self-serving fearmongering is being created around treatments for ideological reasons.

Lui Asquith, spokesperson for Mermaids, an organization that supports trans youth, has intervened in the controversy, recalling that the affirmative approach, which respects the desire of the young person, is not at odds with a good psychological examination without prior expectations.

For Miquel Missé, the sociologist author of

, the affirmative models are a pendulum response to the previous rigid approach, which required psychiatric examinations and medical justification to be recognized as transsexual.

“I spent five years at the Hospital Clínico de Barcelona answering questions like if I like rugby or dolls.

In some cases, harsh medical examinations have gone to the other extreme: it is enough for a person to say that they are trans to start treatment, without asking anything else, which raises problems, of course.

But the caricature that is sometimes made is not very honest.

If an adolescent asks for a gender transition, it is because he has discomfort, and what we have to do is find out the cause and accompany him on the basis that what he wants is to live better”.

The increase in gender transitions is causing a reaction throughout Europe and the United States against affirmative gender identity policies, so that many professionals now move between the fear of being labeled transphobic by LGTBI groups if they put obstacles to treatment, and the belligerence of families and organizations that reject gender diversity.

And the pendulum begins to swing to the opposite side.

The Karolinska Hospital in Stockholm announced on May 12 that it was abandoning, like the rest of the services, the affirmative approach after the National Board of Health and Welfare, the body that evaluates health benefits in Sweden, published new recommendations in this regard.

The agency had found a "considerable increase" in the number of young people seeking care for gender dysphoria, especially between the ages of 13 and 17 and among people who were female at birth: "Various explanations have been given, but the truth that we have not been able to clarify what the cause is, ”said Thomas Lindén, spokesman for the Board, when giving an account of his decision.

Families have little to say, except to reset beliefs and accompany in uncertainty

Carmen Sánchez, promoter of the group Trans Familias

In the aftermath of

in the UK, the Swedish National Board had commissioned a review of published studies on the efficacy and safety of hormone treatments, and the conclusion had been devastating: “It is not possible to draw firm conclusions based on scientific evidence”.

Regarding regrets, the Board specifies that it is also not possible “to determine the frequency with which people who undergo treatment change their minds, interrupt it or regret it”.

The final conclusion is: “The risks of puberty-blocking and gender-affirming hormone therapy in those under 18 years of age currently outweigh the possible benefit for the group as a whole”, so it recommends abandoning the policy of indiscriminate administration and reserve these therapies only for exceptional cases.

The measure has caused desolation in trans groups, who appeal to the guidelines of the Association of Transgender Health Professionals.

These professionals consider that putting barriers to the access of adolescents with gender dysphoria to puberty blockers can cause “lasting damage to their health”.

In the United States, four states governed by Republicans (Alabama, Arkansas, Texas and Arizona) have approved regulatory changes to restrict the access of trans youth to gender-affirming therapies, in open opposition to the federal policy of President Joe Biden. , favorable to eliminating barriers and facilitating access to treatments.

For now, the federal government has managed to temporarily block some of these reforms, but there are 15 other states that are considering or processing similar laws.

Placing trans youth at the center of the culture war can only have negative consequences.

Regardless of how the scientific evidence on treatments evolves, the fundamental thing, in the opinion of Cristina Garaizabal, is that adolescents with gender dysphoria have time and space to experience and reflect on their discomforts;

that they can reconcile with their body, which does not imply either stopping or dissuading, but showing that there are more possibilities than the male-female dichotomy.

As for the little ones, she believes that their preferences should be validated and let them have the gender expression they want, but she is not in favor of classifying them as trans children from the outset "if that entails a roadmap with blockers and hormonal treatments so that they have a good

”.

Neither slow nor encourage.

This is also the philosophy with which the team of the gender identity unit of the Sant Joan de Déu Hospital in Barcelona works.

"The fact that there are transitions should not imply a limitation in access to rights and good medical care for people who need it," says Marcela Mezzatesta.

For Agustí Bonifacio, who deals with the social part, the fundamental thing is that young people can ask for help if they have doubts, and explore their preferences without assuming a point of arrival.

The first objective of Paula Molina, the unit's endocrinologist, is to ensure that the information they have is realistic and tailored to their needs: "There is no pharmacological treatment, much less surgical intervention, that is indicated in all cases. .

Hormonal treatment is not essential to make a transition”, he maintains.

The team considers it very important to achieve the participation of families, even those who do not understand the process in which their children are.

It is very common for the teenager to go with his foot on the accelerator and the parents with the handbrake on.

For most parents, the transition is an ordeal they don't know how to deal with.

"One thing is to accept and another to understand," says Carmen Sánchez, promoter of the Trans Familias group: "When the child goes through, the family goes through and the parents are very afraid of failing."

They need to place their children on some recognizable map, but the process is winding, a few days forward, others backwards.

“In reality, families have little to say, because each person is the owner of their identity, except to reset many of our beliefs and accompany them in uncertainty.

It is a complex situation because it puts us in crisis.

But the best we can do is leave space, give them air.

And accept that when our children hit the road, the place they arrive may not be as wonderful as they think.

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