The debate about the use of puberty blockers for gender dysphoria erupted in Italy on January 12 when the Italian Psychoanalytic Society (Società Italiana di Psicanalisi, SPI) issued a call to the Ministry of Health signed by its president Sarantis Thanopulos. The document expresses “great concern” about the use of drugs that block pubertal development of minors diagnosed with gender dysphoria. The concerns are followed by a list of warnings based on the idea that the “ongoing trials circumvent careful scientific evaluation.” Finally, the document calls for a “rigorous discussion.”
“The diagnosis of ‘gender dysphoria’ in prepubertal age is based on the claims of the concerned individuals and cannot be subject to careful evaluation as long as the development of sexual identity is still in progress,” the document stated. “Only a minority of children who state that they do not identify with their gender confirm this statement after puberty. Suspending or preventing psychosexual development while waiting for the maturation and definition of the child’s stable identity is in contradiction with the fact that this development is a central factor in the process of identity definition.”
And the psychoanalytic society continued: “Even when the declared ‘gender dysphoria’ in prepubertal age is confirmed during adolescence, the developmental arrest won’t result in a body that is different, from a sexual point of view, from the original one. The sexual development of the body, even when it contradicts the internal orientation, allows an erotic fulfillment that a ‘blocked’ or manipulated body does not offer.”
The SPI is an important pillar in the history of psychoanalysis in Italy. It was founded in 1925 and officially recognized by the International Psychoanalytic Association (IPA, established by Sigmund Freud) in 1936. It gathers medical doctors and psychologists trained in Freudian psychoanalysis.
“It’s not the first time that there has been an attempt to interfere with the prescription of puberty blockers,” Alessandra Fisher, MD, president of the Italian Society of Gender Identity and Health (SIGIS) and head of one of the most experienced public centers dealing with young people with gender dysphoria at Careggi Hospital in Florence, told Medscape Medical News. “Nonetheless, the influence of SPI, both from a scientific and societal point of view, demanded an answer.”
Other Groups Respond
The answer came as an open letter issued by a large number of scientific societies, including SIGIS, the Italian Society of Endocrinology (SIE), the Italian Society of Pediatrics, the Italian Society of Pediatric Endocrinology and Diabetology, the Italian Society of Andrology and Sexology, the Italian Society of Pediatric Psychiatry, and the National Observatory on Gender Identity. Even the Italian Society of Psychiatry and the National Order of Psychologists expressed their concerns and disagreement with their own official statements.
“The text describes the treatment with hypothalamic blockers in adolescents with gender dysphoria as an experimental treatment, but it’s not,” explained Fisher. In fact, the therapy was approved by the Italian regulatory agency AIFA in 2019 following a favorable 2018 opinion from the National Bioethics Committee.
“Such medical treatment is reserved for carefully selected cases, following multidisciplinary and personalized evaluation,” stated the scientific societies’ document. “We agree that the scientific data available to date confirm that gender identity reaches stability at pubertal age (and not in prepubertal age or in childhood); therefore, as widely documented in international recommendations, hypothalamic blockers can be prescribed only when puberty is already underway,” the experts explained.
Endocrinologists and pediatricians also highlighted the fact that transgender adolescents are more vulnerable and have higher rates of depression, anxiety, and suicide risk as a result of the distress associated with a body that does not reflect one’s gender identity.
“Despite what was stated in the document by SPI, follow-up studies show that treatment with puberty blockers can significantly reduce behavioral and emotional problems and suicidal risk, as well as improve overall psychological functioning in adolescents,” Fisher added.
Disagreement Among Psychoanalysts
The strong reaction by the medical societies has not cast doubt in Thanopulos’ mind, and no official disagreement has emerged from other members of SPI.
“There are no rigorous, carefully collected, and independently controlled data, nor studies on the difference in terms of suicide between allegedly transgender kids who take the drug and those who do not,” Thanopulos told Medscape. “Dysphoria often coexists with mental disorders such as depression, eating disorders, or autism spectrum disorders. We need a differential diagnosis, but few people deal with it.”
The medical environment unanimously condemned the statement by the SPI, but, according to Thanopulos, it’s a matter of cultural approach. “For our scientific society, to remain silent would be a betrayal of its ethical and scientific principles. Many pediatricians are also sensitive to the problem, but they do not have the tools to deal with it, and their associations are facing a common problem in medicine: the estrangement from medical philosophy and psychology. We discussed within SPI how to communicate the issue, adopting terms that would not make our statement repressive. We ask for an open debate, but, unfortunately, most physicians and some psychologists not trained in psychotherapy comply with the strong support for hormonal treatment.”
Not all psychoanalysts agree with their main scientific society. Vittorio Lingiardi, MD, psychiatrist and psychoanalyst, professor of dynamic psychology at University Sapienza in Rome, published a strong editorial against the SPI document in La Repubblica, one of the major Italian newspapers, and entitled it “Ideology Without Science.”
Annamaria Colao, PhD, president of the SIE, told Medscape that she is worried about the impact on the young people affected by gender dysphoria. “Thanopoulos’ document states that it’s wrong to assess the gender identity on the subject’s statements, but self-perception is in fact the basis of all assessments in psychology, even in psychoanalysis! This kind of statement will generate unwarranted alarm among young people with gender dysphoria and increase their suffering and the prejudice in those who deny the fact that gender identity may be incongruent with the gender assigned at birth.”
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