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‘It’s a real balancing act for doctors at gender clinics’

Do young people who want to change gender have the unconditional right to medical treatment? Pediatric Endocrinologist Martine de Vries, who is also Professor of Medical Ethics, treats transgender children and adolescents. She will discuss this in her ‘Pride Talk’ on 18 September.

Children and adolescents from all over the Netherlands come to the Curium-LUMC gender clinic. Some are only six years old, but have spent most of their young lives struggling with their identity and body. At present, only the LUMC and VUmc (see below) offer a full treatment programme for children and adolescents with ‘gender dysphoria’: a deep feeling of discomfort with the sex in which you are born. A multidisciplinary team of doctors, psychiatrists and psychologists hold meetings with the children and their parents. In the first phase, these are mainly with a psychiatrist or psychologist. Medical treatment comes into the picture later on. De Vries: ‘Young children are only offered advice, such as feel free to wear “girls’ clothes,” but begin by trying this out at home or in another safe environment.’

What does a treatment programme involve?

‘For about 80% of the young children who come to us, the strong unease disappears as they become older and start puberty. The meetings here usually stop then. Those who persist qualify for puberty blockers from around the age of 12. These are medicines that block the production of sex hormones that are responsible for breast development or beard growth. This gives adolescents more time to think about what they want. But we do let them experience the first phase of puberty because this may also cause them to change. From around the age of 16, adolescents can start taking cross-sex hormones, the hormones of their desired gender and from the age of 18, they can undergo an operation.’

You are a paediatrician and Professor of Medical Ethics and Medical Law. What is your role in supporting these children?

‘As a paediatrician, I check the physical condition of children who come here. At a later stage, if treatment is being considered, I look at whether it is physically responsible to start puberty blockers or cross-sex hormones. For instance, there are risks for adolescents who are heavy smokers or very obese. Or if they suffer from severe depression. Hormone treatment isn’t a magic wand that you wave to solve their problems. That is why we work in a multidisciplinary team of doctors, psychiatrists and psychologists. We discuss dilemmas or difficult cases in an ethics meeting, or the teams from the LUMC and VUmc discuss them with each other. One thing is clear: there are no obvious answers and a lot of research is still needed.’

What kind of research do you do?

‘With my research group, I researched which ethical issues are at play at treatment centres and gender teams like ours all around the world. This revealed that these teams all face the same dilemmas. Should we be cautious about irreversible treatments as long as the cause of gender dysphoria remains unclear? Or until more is known about the long-term effects of treatment? Can young people decide on such radical treatment?’

What are the dilemmas?

‘How do you deal with the loss of fertility? Transgirls can have their sperm cells frozen before they start oestrogen treatment. Transboys should be able to freeze their eggs. This is to ensure that the option of biological children isn’t ruled out completely. But that means that you have to masturbate or be hormonally stimulated to develop egg cells. That is often a big barrier if your body disgusts you. Very few young people make use of the option of storing sex cells. The question is whether you can make good decisions about these kinds of things at a young age.

‘That is why our other research is about whether children and adolescents with gender dysphoria are competent to decide on their treatment programme. How do they see this and how do they feel a certain number of years later? I can’t offer any conclusions as yet. We’ll probably have finished the study this autumn. Tailored solutions and multidisciplinary treatment teams are definitely needed, but the latter is not a given abroad.’

How accepted are transgender treatments in the Netherlands?

‘In recent years they have received a lot of positive attention, thanks also to TV programmes such as Hij is en Zij [‘He is a She,’ ed.]. But more recently, there has been a lot more discussion about whether and how we should offer these kinds of treatment. Critics, including some doctors, believe that you shouldn’t intervene if the body is healthy and that you shouldn’t influence puberty. In contrast, worried interest groups think that the waiting lists should be shorter and treatments quicker. It’s a real balancing act for us.’

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Parents can register their children at VUmc [in Dutch]. Until this year, they would then be referred to the LUMC or the larger treatment centre at the VUmc. However, the LUMC-Curium gender team is currently too small to preform all the tasks alongside patient care that belong to an expertise centre. The LUMC is therefore not accepting any more new applications. De Vries says this is regrettable because there is now a waiting list of almost a year, with over 700 children and adolescents. However, Radboudumc will be opening a treatment centre with a gender team in 2020.

Watch the Pride Talk by Martine de Vries

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Watch the Pride Talk by Michael Kirby

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