The European Society of Child and Adolescent Psychiatry (ESCAP) published a policy statement on child and adolescent gender dysphoria. ESCAP is a highly respected umbrella association of 36 Child and Adolescent Psychiatry societies (see Table 1). It enables collaboration among child and adolescent psychiatrists across Europe and holds a widely attended bi-annual professional conference for European child and adolescent psychiatrists.

The thrust of the ESCAP statement is the call on healthcare providers "not to promote experimental and unnecessarily invasive treatments with unproven psycho-social effects and, therefore, to adhere to the 'primum-nil-nocere' (first, do no harm) principle." ESCAP pointed to the "poor reliability and instability of a gender dysphoria diagnosis in a specific child over time" and the "possible effects of the decisions to block puberty or preventing medical transitioning on a child's psychosocial development." ESCAP allowed for the possibility that some children may benefit from gender reassignment but acknowledged the current lack of quality research to determine the risk-benefit ratio. ESCAP made an important call to differentiate between experimental practices and established medical treatments and articulated several key recommendations that focus on generating quality research in the area of gender dysphoria management for youth.

ESCAP also insisted that "research findings are published solely on the grounds of quality criteria and not based on their findings," suggesting that it is concerned about the publication bias whereby studies reporting favorable youth transition outcomes are frequently published even if they are deeply methodologically flawed.

ESCAP centered the core ethics principles, putting them in the context of gender dysphoria treatments in youth:

1. The principle of non-maleficence: do not use outside the research environment any experimental interventions with potentially irreversible effects, or interventions with unknown long-term consequences; do not adopt new practices prematurely without sufficient evidence; do not continue with outdated practices that might not be in the best interest of the patient.

2. The principle of beneficence: adopt medical interventions with favorable benefits-to-harms ratio; consider benefits-to-harms ratio of not providing medical interventions; ensure adequate diagnosis and treatment of co-existing psychiatric disorders; ensure comprehensive diagnostic assessment of gender dysphoria instead of only relying on the self-assessment of children and adolescents

3. The principle of autonomy: involve minors in the decision-making processes around their care in an age- and development-appropriate manner, assessing their capacity to consent; adopt an adequate informed consent process for possibly lifelong and irreversible decisions, securing that children and adolescents fully understand the potential risks, benefits, and irreversible nature of the treatments; consider the rights of their parents and guardians to consent to any major intervention or for participation of their children in research on experimental treatments; consider the rights of their parents and guardians to be fully informed about the current care for their children; offer adequate support and resources to those who decide to de-transition to their assigned sex, and respect their decision to do so.

4. The principle of justice: ensure access to reliable and up-to-date information, assessment, and treatment for gender dysphoria, and during transition or de-transition; adopt equal precautionary measures for all; and protect the rights of children and young people as a group in a particularly vulnerable developmental phase.

Table 1: The European Society of Child and Adolescent Psychiatry (ESCAP) membership

Finally, ESCAP reasserted the need for open debate, noting that "respect for all kinds of different views and attitudes is an essential part of an ongoing open professional debate that we wish to stimulate."

SEGM Take-away

ESCAP is a highly regarded association of psychiatrists who treat children and adolescents in Europe. While some European countries have reversed the practice of youth transitions (e.g., Finland, Sweden, UK), others still consider it an appropriate first-line treatment (e.g., Germany, Belgium, the Netherlands). This most recent ESCAP statement is likely to be noted by many more child, adolescent and adult psychiatrists in Europe, furthering current important discussions and debates.