A German Sonderweg

German-speaking countries ramp up 'gender-affirming care' for minors in a time when many countries move away from it. This could have far reaching consequences for the entirety of Europe.

Even though they are fairly socially conservative countries, trans activism has had a field day in German-speaking countries (Germany, Austria, Switzerland). With Switzerland passing gender self-ID in 2022, Germany following suit in 2024, pushing forward pediatric gender-related medical interventions was the next logical step. So it proved that on March 6, 2025 a consortium of medical and psychotherapy organizations adopted new guidelines as to the “treatment of gender dysphoria/incongruence in children and adolescents.” The original draft was made public in April 2024. The final version has seen some changes to the original draft version but the main message still stands: It views medical intervention as the “sole effective treatment” for persistent “gender incongruence.” Given the combination of legal sex entry changes now possible for minors under gender self-ID and the expanded access to medical transition services, the number of children undergoing sex trait modification procedures is likely to rise significantly.

For the first time, there is now a detailed protocol for handling gender dysphoria. Previously, decisions about whether to prescribe puberty blockers or cross-sex hormones to gender-distressed children were made on a case-by-case basis. Now, clinicians have a comprehensive handbook to guide them. At a time when many European countries are scaling back pediatric transition, German-speaking countries are moving in the opposite direction. This creates a powerful transaffirmative bloc in the heart of Europe, with a combined population of roughly 100 million people, a total GDP of nearly 6 trillion USD (almost twice that of the UK), and healthcare systems among the largest in Europe (measured by healthcare expenditure as a percentage of GDP). Through EU cross-border health insurance, this development may enable children and adolescents from across Europe to access pediatric transition services.

A selection of flaws

According to the guidelines’ authors, the central ethical dilemma of pediatric gender care is this: medical interventions are often irreversible, but refusing them can exacerbate distress as puberty entrenches the sex traits causing the dysphoria. Therefore, when a diagnosis of “gender incongruence” persists alongside severe gender-related distress (though the guidelines do not clearly distinguish between the two), medical transition is considered safe and effective—even for children with trauma, psychological comorbidities, or autism. While the guidelines acknowledge that transition is not appropriate for those experiencing temporary dissatisfaction with their sex, they do not provide a method for distinguishing between transient and persistent cases.

This is particularly disturbing in light of a 2024 study by Bachmann et al. (2024) which goes through German (!) patient records and finds that only for 36 % a diagnosis of gender dysphoria persists for more than 5 years. Ironically, this study was not even mentioned in the guideline publication. So, where is the magical threshold for persistence?

There is no need to recite the obvious flaws of the new guidelines and how the authors misrepresented independent reviews of the evidence such as the Cass Review. The Society for Evidence-Based Gender Medicine (SEGM) already summarized the main points succinctly.

There is a strange discussion as to near-certainty of sterility following medical transition of minors. The almost certain sterility resulting from being put on puberty blockers and subsequently on cross-sex hormones is acknowledged but put into context with the possibility of cryopreservation (removal of sperm or ova and deep freeze for later use). But this effectively requires children in their teenage years to make irreversible decisions about future children.

At the very end of the guideline recommendations, the authors of the guideline do state potential health complications of cross-sex hormones. For instance, boys taking estrogen have elevated risks of breast cancer and testosterone in girls increases vaginal atrophy, raises LDL cholesterol and hence increases the likelihood of cardiovascular disease. As the relevant comparison group for trans-identified children taking cross-sex hormones are not the target sex but their own sex, this is somehow admitting that cross-sex hormones actually do cause measurable adverse health effects. And there is a national precedent for experimenting on female bodies with male sex hormones. In communist Eastern Germany (GDR), female (and male) athletes were given testosterone and anabolic steroids (which are derived from testosterone) to enhance performance in a desperate need to score some wins for the otherwise failing communist regime. The long-term health effects were devastating. The psychologist Harald Freyberger analyzed health records of athletes in retrospect and found the following overall long-term effects:

“"Victims of doping in the former GDR die on average ten to twelve years earlier than the general population. And another shocking statistic: a GDR doping victim is about 2.7 times more likely to fall ill; for mental illnesses, we even found a factor of 3.2.”

Women who were given hormonal doping and became pregnant had a much higher incidence of miscarriages and stillbirths and their babies often suffered from birth defects. Of course there is no 1:1 mapping of gender-related hormone treatment and sport-related hormonal doping but there are overlaps. Women who received doping showed signs of masculinization like a deepened voice, hair growth or damage to their reproductive systems we know from testimonies of trans-identified females. And worryingly, according to the German parental interest group of trans-identified children “TransTeens Sorge berechtigt” (engl. trans teenangers, caution is warranted) the doses of synthetic testosterone used for transition exceed those of androgen doping by a factor of 2.25 to 3.5.

At its core, it is now the view of the medical profession in German-speaking countries that there are in fact children born in the wrong body, they just have to be correctly identified. Once identified, transition is deemed safe and effective at reducing gender dysphoria. It remains astonishing that doctors thoroughly trained in biology really think that it is actually possible to turn a natal boy into a woman or vice versa. A subtle but grim implication of this belief is that there are ‘trans children’ which are effectively second-class because unlike their ‘cis’ counterparts, they will be denied full sexual function in adulthood and the option of having their own children as a consequence of transitioning. It becomes even darker when you remember that many of these children have other psychological comorbidities and show signs of same-sex attraction.

Implications for the whole of Europe

A subtle feature of this newly arisen transaffirmative bloc in the heart of Europe is that it will have ripple effects across the continent. Directive 2011/24/EU of the European Parliament and of the Council states that citizens of the European Union (27 member states) and European Economic Area (EU plus Norway, Iceland and Liechtenstein) are entitled to seek healthcare anywhere in the EU/EEA. So in principle, parents seeking to transition their child can now access the much more liberal regime in German-speaking countries (Switzerland is a different matter as it is neither a part of the EU nor EEA) if puberty blockers or cross-sex hormones in their home country are less accessible. There are certain limitations to cross-border access, most notably:

• Home country health insurance will only reimburse the costs incurred abroad that would be covered at home, and payment typically needs to be made upfront. So if a country in principle allows childhood transition, national health insurance could cover the costs of treatment in Germany or Austria.

• For certain types of healthcare (e.g., hospital stays or treatments requiring planning), prior authorization from the home country may be required.

Also, prescriptions can be used throughout the EU and EEA. Certainly, given the uncertainty about coverage at home, it will mostly be children of high-income families seeking treatment in Germany or Austria. However, with countries like Sweden or Italy scaling back on pediatric transition we must assume that families firmly embedded in the belief that their child was ‘assigned a wrong sex’ will exploit the differential in transition availability. People respond to incentives and as we know from famous cases, parents who firmly believe that their girl is actually a boy or vice versa will go to great lengths to ensure her sex traits are aligned accordingly. Susie Green sending her trans-identified son to Thailand for genital surgery is just one very famous example.

Similar cross-border differentials in service provision were exploited by Anne Trans Healthcare, Susie Green’s own private childhood transition provider. Before the UK government prohibited the sale of puberty blockers to minors by private providers in the EU/EEA in December 2024, this was apparently the way to get these medications as the Reddit screenshot below suggests. Patients would receive a prescription from trans-affirmative non-UK doctors and as prescriptions from any EU doctor are valid in Ireland (or Northern Ireland which is still part of the European single market), they had to travel to these countries to receive said medication.

Fuel to a well-oiled gender medicine machine

While it is mostly English-speaking countries that receive journalistic coverage when it comes to the explosion of pediatric medical transition, Germany is no exception to that trend. An article from the UK newspaper The Telegraph revealed that, according to GP records roughly 10,000 minors received or maintained a diagnosis of gender dysphoria in 2021. The 2024 Bachmann et al. study on German medical records showed that in 2022, 19,500 5-19 year olds had such a diagnosis. The total number is likely higher as this number only refers to public insurance data. A study by Leor Sapir from the Manhattan Institute estimated the number of American minors diagnosed with gender dysphoria to be around 100k in 2023.

If you take into account the different size of minor populations in the respective countries you end up with 1 in 1440 minors in the UK having a diagnosis, 1 in 740 in the US and 1 in 774 in Germany. Obviously, a diagnosis does not directly translate into medicalization. But if we compare transgender genital surgeries across all age groups (data available for a few countries) and interpret this as an indicator of the availability of transition services, you can see in the figure below that genital surgeries in Germany happen roughly 3.5 times more often than in the UK.

Even though, German law strictly prohibits sterilizing medical interventions on minors (with the exception of truly life-saving interventions), official data from Germany’s statistical office show that genital surgeries on minors (which necessarily result in permanent sterility) are performed on minors for gender related reasons. While in 2005, none of those were performed, 2023 saw 38 transgender genital surgeries on patients under the age of 18. The number of transgender surgeries is only the very thin tip of the iceberg of youth gender medicalization. Hence, a large multiple of young boys and girls undergoing surgery will have been put on puberty blockers and exposed to cross-sex hormones.

While it is difficult to estimate the full extent of pediatric transition, the fairly high incidence of gender dysphoria diagnoses and genital surgeries on minors suggests a fairly active gender medical industry. And with clear pro-affirmative guidance in place, it’s only natural to assume that the number of minors undergoing medicalization will continue to rise. More demand will also create more supply, which can then be accessed from all over Europe.

Even though the extent of medical transition in Germany seems to be much larger than in the UK, unbiased coverage in mainstream journalism is rare. The Cass Review and the ensuing restrictions by a left-wing British government have almost produced zero headlines. Rather, media outlets frame the topic in the liberal American context, suggesting that bigoted Republicans want to take away life-saving healthcare from vulnerable children. In a classic form of Trump derangement syndrome and amid escalating trade conflicts across the pond, any decent reporting on the actual state of the evidence and the stakes for the children involved would imply giving any credit to Donald Trump.