Trans children: what do child psychiatrists think?

As preparatory work by the Haute Autorité de Santé is due to begin at the end of this year, with a view to developing good practice recommendations on the support of trans minors, a research article published in the journal Neuropsychiatrie de l’enfance et de l’adolescence reports on a study based on interviews with French and Belgian child and adolescent psychiatrists on the care of prepubescent children experiencing gender incongruence.

Between April 2022 and July 2023, the research team conducted interviews with 12 child and adolescent psychiatrists who had recently been involved in the care of such situations. The psychiatrists interviewed, 6 men and 6 women, were all cisgender, and 8 were specialised in this field. The interview period followed the publication of the so-called “Blanquer” circular (September 2021), which allows social transition for students of any age within the French national education system – without the need for psychiatric certification and subject to parental consent – and also followed the ban on conversion therapies (January 2022). It also coincided with the publication of the 8th version of the WPATH Standards of Care (August 2022), which recommends, among other things, “that parents/caregivers and health professionals support children who wish to be recognised in the gender that corresponds to their internal sense of gender identity” (p. 88).

Contrary to what the authors of the article claim in their introduction, recent scientific evidence no longer supports the idea that there is a “significant risk of desistance at the onset of puberty.” The literature on social transition in children, reviewed by Hall and colleagues (2024) and taken up by Hilary Cass (2024, pp. 161-165), or by the AWMF (2025, pp. 61-64) for example, highlights the low risk of desistance when the psychosocial and clinical environment is supportive, which was not the case in older studies (see in this regard the critical review of the literature by Temple Newhook and colleagues, 2018). This is notably the case in the Trans Youth Project study by Olson and colleagues (2022), which “found that 93 % of individuals who had socially transitioned between ages three and twelve continued to identify as transgender at the end of the study (approximately 5.4 years later). Among the others, 2.5 % were living as cisgender, 3.5 % as non-binary, and 1.3 % had undergone two re-transitions” (Cass, statement 12.25, p. 162).

It should be noted that this same Trans Youth Project led, in 2025, to a scientific monograph by deMayo and colleagues, discussed here by Trans Youth Trajectories, which confirms the high stability of gender identity among children who have socially transitioned, including when compared with cisgender children, whether siblings or children from other families. This therefore raises the question of the scientific justification for child and adolescent psychiatric consultations for prepubescent children who are socially integrated in their affirmed gender, in the absence of any psychiatric comorbidity.

The article discussed here, written by Lucia Montecchio and her colleagues, immediately reveals a shift in the therapeutic framework under the influence of an all-pervasive social debate: “It’s how much people in society ask us questions about this […] me, as a child psychiatrist, I should be a reference point on the issue of gender incongruence […] Around me, all the time people ask me questions […]” (C1, E5, Table 5). This interpenetration of the social and the clinical feeds defensive stances and, at times, a recentring of decision-making power on healthcare professionals rather than on the children concerned.

Some clinicians interpret the increase in consultations as a fashion phenomenon, even as an “epidemic”: “You know, 10 years ago, there were no requests […] there really are fashion effects. The problem is when are we going to question the meaning of the epidemic?” (C2, E3, Table 5). This lexical framing (“fashion,” “epidemic”) risks pathologising life trajectories and obscuring attentive listening to the child’s lived experience, even though France introduced, in January 2022, following the World Health Organization, the removal of trans identities from the category of mental illnesses.

The child and adolescent psychiatrists also describe a blurring of their professional role under pressure from the public sphere: “[…] everyone has an opinion about it […] society comes in and takes hold [of the issue] […] I see extremely severe cases of anorexia, nobody cares. But gender incongruence […] everyone goes completely crazy about it” (C3, E5, Table 5). This perception of “interference” can lead to a stance of over-control, crowding out the work of open-ended support for the child and their family.

Politics surfaces clearly in clinicians’ accounts: “The hospital decided to launch a gender clinic under political impetus […] but without a physician […] it’s essentially a political problem” (C5, E3, Table 5). Yet reading these situations solely through the lens of politico-institutional conflict risks losing sight of a child-centred ethics of care.

In the study by Montecchio and colleagues, certain positions hostile to associations stand out clearly: for instance, one child psychiatrist describes the creation of a “gender clinic” “under the impetus of associations,” framing it as “a political problem” (C5); another considers that “LGBTQIA+ associations remain somewhat sceptical about the role of psychiatrists” and refers to risks of “blacklisting” (C7, E12, Table 5); a third speaks of a “conflict of interest” insofar as some clinicians might be “activists in LGBTQIA+ associations” (C8, E3, Table 5). These assertions, which construct associations as forces of interference rather than as partners in care, depart from the spirit of health democracy enshrined in the so-called “Kouchner” law (2002), as well as from the most recent clinical recommendations (AWMF, 2025). The latter explicitly require that the social environment receive “educational and information services, which also refer to information and counselling services offered by self-advocacy organisations of trans people and their relatives” (Statement IX.K5, p. 263), thereby affirming the structuring role of associations in the psychosocial support of minors.

In addition, the AWMF recalls in its introduction that its guideline was developed with “Twenty-six medical and psychotherapeutic societies as well as two self-advocacy organisations were involved in drawing up and agreeing on the guideline,” as a guarantee of co-construction with service users (p. 2). In other words, where some clinicians describe associations as vectors of pressure (C5, C7, C8), the AWMF framework recognises them as legitimate and necessary interlocutors in care pathways and risk prevention, and encourages health professionals to actively refer to them. It is worth noting, moreover, that some child and adolescent psychiatrists align with this view: “[these associations] stay informed, (…) are vigilant” and act “in a very loyal and very, very healthy way” (C6, E2, Table 5), an assessment that precisely echoes the partnership-based approach promoted by health democracy.

Some excerpts document explicit gatekeeping (control): “[…] we need a psychiatrist who will tell us who the real and the fake trans people are […] they wanted someone to be responsible” (C18, E7, Table 5). Yet this delegation to child and adolescent psychiatrists of an arbitral function over “real/fake” identities stands in tension with the AWMF recommendations: “In children before the onset of puberty who show signs of childhood gender incongruence, health professionals should assume that it is not possible to predict persistent gender incongruence in adolescence until the onset of puberty.” (Recommendation II.K3, p. 57). In other words, developmental uncertainty calls for non-presumptive support, not identity certification.

Clinicians also report a sense of being instrumentalised around puberty blockers: “[…] with children, I have more the impression that they really come seeking this puberty blocker treatment […] we feel instrumentalised […] and that they are in an expectation that will be only that […]” (C19, E11, Table 5). And the pressure felt can become “unbearable”: “I want this […] give me what I want […] right now” (C20, E3, Table 5). Some stances then assert a firm temporisation: “We are just going to support you to limit the risk that he develops a reactive mental illness […] I never accept being put under pressure […] if I don’t feel it […] well, manage without me […] we take our time” (C46, E1, Table 5).

The concern not to give in to haste is legitimate. But it must be articulated with clinical recommendations grounded in scientific evidence: the AWMF thus recommends opening safe spaces for gender exploration in a reversible way and without presuming the outcome, in order to support exploration and, where appropriate, improve later decision-making regarding medical interventions (VI.K3: “safe social space,” p. 137). Caution is not inaction: it is the establishment of a secure framework guided by the child’s needs and voice.

The empirical material moreover shows that psychosocial support improves children’s wellbeing: “anxiety symptoms improve […] [Name] starts playing the guitar, has a few more friends […] we see the effect it has, if it’s positive, we maintain it […] Precisely, we try to support” (C47, E10, Table 5). This converges with scientific evidence: in Chapter III, § 4.2 (AWMF, pp. 56-58), psychosocial support, information about varied trajectories, and the reversibility of social steps are presented as useful interventions regardless of any future decisions about possible medicalisation.

Under conditions of anonymity, several clinicians describe their exhaustion in the face of “pressure” and the lack of shared reference points. The risk, then, is a return to a logic of epistemic paternalism (the physician decides, the child aligns) rather than informed shared decision-making. The AWMF, cautious about levels of evidence, precisely proposes a procedural roadmap: transparent information, explicit acknowledgement of uncertainty, co-decision, family and school safety nets, and the possibility of going back without stigmatisation (II.K1-K3, pp. 56-58; VI.K5-K6, pp. 137-138). This is the infrastructure that allows the child to be heard without trapping them, either through acceleration or through obstruction.

Overall, the study reveals a contrast: the more social pressure is felt, the more some child and adolescent psychiatrists harden into positions of control, at the risk of undermining children’s self-determination. Yet the AWMF insists that the progressive autonomy of minors in matters of gender identity must be recognised and supported; and that “delaying or preventing” without proportionate justification can increase suffering (ethical reminder in the preamble; and, in practice, § 4.2 of Chapter III on recommendation III.K2 supporting self-determination in children’s social transition). The balanced path is clear: precaution (acknowledging uncertainty, avoiding premature over-medicalisation), openness (social exploration within a secure, reversible framework, VI.K3), family support (VI.K5-K6), and centring the child’s voice (II.K1-K3). It is this architecture – and not suspicion (“fashion effects”) – that truly offers protection.

In other words, to the question “how do we avoid making a mistake?”, the article responds indirectly: by relinquishing the power to decide who is “real” or “fake,” by defusing pressure through reversible frameworks (VI.K3), and by making the child a co-author of their trajectory through clear information about the range of possibilities, including detransition (II.K2). This is precisely the spirit of the AWMF recommendations (Chapter III, § 4.2, pp. 56-58): care grounded in self-determination, co-decision, and non-predetermination of outcomes. Under these conditions, teams move from a role of “gatekeepers” to the more demanding role of guarantors of a safe space in which children can genuinely determine themselves.