2025 German Guidelines for Diagnosis and Treatment of Gender Incongruence and Gender Dysphoria of Childhood and Adolescence

SEGM - 26 mars 2025

https://segm.org/German-guidelines-gender-dysphoria-youth-2025?utm_source=substack&utm_medium=email

Despite the new cautious tone, the Guidelines remain non-evidence-based and pave the way for ongoing inappropriate youth transitions

Summary

Key points:

1. The German Guidelines failed to reach the originally intended S3 “evidence-based” threshold and were downgraded to S2k “consensus-based.”

2. Following the German and international criticisms, some of the original recommendations were revised towards more caution.

3. The final Guidelines acknowledge that the vast majority of gender-distressed adolescents today merely have "gender non-contentedness" and should not medically transition.

4. Despite the more cautious narrative, the Guidelines’ recommendations remain largely unchanged, providing a pathway for any willing clinician to provide gender transition to any determined youth.

5. The Guidelines have evidence of significant unmanaged conflicts of interest, including a priori alignment with WPATH positions, leadership in gender clinics and organizations promoting gender transition treatment, and ties to pharmaceutical companies.

6. The Guidelines’ scathing analysis of the Cass Review is based heavily on the discredited “Yale” report and is rooted in a misunderstanding of the role and process of “independent reviews.”

7. Two German medical societies fully rejected the final Guidelines, and several more issued alternative recommendations. Switzerland has not yet accepted the Guidelines, initiating its own additional review.

8. Continued reliance on consensus-based guidelines written by gender-affirming clinicians with unmanaged COIs is not justifiable and will continue to polarize the field.

9. There is an urgent need for high quality evidence-based guidelines developed to a high methodological standard.

10. Evidence-based guidelines allow for consideration of other factors besides the strength of the evidence. However, they bring a level of rigor and transparency which allows guideline users to make true informed decisions—something that consensus guidelines cannot achieve.

In March 2025, the Association of the Scientific Medical Societies in Germany (AWMF) published the final version of the Clinical Practice Guidelines on the Diagnosis and Treatment of Adolescent Gender Dysphoria and Gender Incongruence (hereafter Guidelines). Besides Germany, the Guidelines are intended to be used in Austria and Switzerland. Although originally intended as “evidence-based” (S3) recommendations, the Guidelines failed to reach this status, and were downgraded to a lower rating of “consensus” (S2k) in January 2024.

The non-evidence-based nature of the recommendations was explicitly acknowledged in an accompanying Guideline Report [Leitlinienreport]:

The explanation provided by the Guideline Group for failing to meet the S3 “evidence-based” level is that poor evidence made it impossible to create an evidence-based guideline. This explanation is only partially correct—the evidence in this area of medicine is indeed poor. However, evidence-based guidelines are always possible to create, as demonstrated by the German AWMF Guidance Manual, which sets out clear steps for developing an S3 guideline: 

1. Conduct a systematic search for evidence (which is always possible)

2. Appraise the evidence for quality; and 

3.  Arrive at treatment recommendations and assign strength to each recommendation, guided by the evidence and informed by additional factors.

The Guideline Group faltered at the first step: conducting a systematic search for evidence. While this effort had been initiated, by 2020 the Group chose to suspend its systematic search for evidence citing funding challenges, and instead chose to rely on the systematic reviews of evidence conducted by the World Professional Association for Transgender Health (WPATH). At the time, WPATH was in the process of conducting their own evidence reviews, which had been commissioned from Johns Hopkins University as part of creating its Standards of Care 8 (SOC8) guidelines. However, the decision to rely on WPATH proved to be a fateful one, after WPATH suppressed the publication of the Johns Hopkins evidence reviews once confronted with unfavorable results—a scientific scandal that has shaken WPATH’s credibility to its core. Having no systematic review of evidence as the basis for their recommendations, the German guidelines lost any claim to the S3 status. The other steps of the evidence-based S3 process were not followed either, as outlined in our earlier analysis of the Guidelines’ methodology. As a result, AWMF appropriately downgraded the Guidelines to the lower S2k “consensus” status.

When the Guidelines were shared with the participating medical societies to seek their adoption last year (in March 2024), the only comments solicited were those related to ”editorial improvements” such as clarity and readability (Zepf et al., 2024, p. 2), discouraging substantive comments about the recommendations themselves. Despite this, the Guidelines' content was met with much criticism—both from a group of Chairs of Child and Adolescent Psychiatry in Germany from DGKJP (the Guidelines' leading authorial society), as well as internationally. Commentators pointed out a number of apparent departures from the core principles of evidence-based medicine and medical ethics. According to the draft recommendations, virtually any teenager wishing to undergo medical gender transition could do so based on the principle of autonomy, with insufficient safeguarding measures in place. In response to the draft release, the German Medical Assembly issued a resolution that urged the German government to limit the use of puberty blockers and cross-sex hormones to clinical trials. The ensuing scientific debate delayed the adoption of the Guidelines by months and resulted in substantial revisions to the Guidelines’ content. 

The final version of the Guidelines, shared with the medical societies in the fall of 2024 and finally adopted in March 2025, is significantly more cautious in its stance than the previously released draft. The most notable revision is clear recognition that most young people with gender-related concerns likely have temporary “gender non-contentedness” and should not undergo gender transition. The Guidelines also more explicitly admit to problems in the evidence and recognize the role of social influence in giving rise to transgender identities in youth, emphasizing the importance of differential diagnosis. Both the original draft and the final version of the Guidelines also state that the ICD-11 diagnosis of “gender incongruence” alone is not enough to justify medical gender transition, and that clinically significant distress must be present. This demonstrates a welcome tethering to the clinical reality of needing to have valid clinical treatment targets beyond an adolescent's desire for a different physical appearance.

However, despite adopting a more cautious narrative, the Guidelines are of little help when it comes to operationalizing the stated need to be conservative in the treatment of the currently-presenting cases of gender dysphoric youth. For example, the Guidelines provide no criteria to differentiate between cases of temporary “gender non-contentedness”—which the Guidelines acknowledge can last several years and should not lead to transition—and “stable/persistent” cases which, per the Guidelines, are eligible for endocrine and surgical interventions (the gender-related diagnoses do not help, as they have low diagnostic stability). Further, the Guidelines allow youth gender transitions in cases of mental illness or autism. It appears that even in their final adopted version, the Guidelines create a pathway for any sufficiently determined adolescent to access hormones and surgery, especially when treated by a “gender-affirming” clinician who prioritizes teenager autonomy above all else.

The Guidelines’ “affirmative” stance is not surprising. The Guidelines disclose that the authors “predominantly share” the views of WPATH and the Endocrine Society (p. 222)—two organizations that have strongly endorsed youth gender transitions worldwide. As the March draft of the Guideline Report transparently revealed (p. 17), the non-systematic search for evidence heavily relied on handpicked (rather than systematically searched) studies taken from WPATH's Standards of Care, Version 8 (SOC8).  We have identified text in the Guidelines drawn nearly word-for-word and paragraph-by-paragraph from SOC8 (examples from one section are provided in Table 1 at the end of this Spotlight). Such a strong alliance with WPATH's pro-medicalization position constitutes a potential conflict of interest (COI).

It is challenging to avoid all COIs in this contentious area of medicine, as many of the most knowledgeable clinicians and researchers have already taken strong intellectual positions (and often also benefit financially from the practice under review). For this reason, COIs must be carefully managed to avoid bias, ideally under independent oversight of external experts in COI management. Unfortunately, the Guideline Group opted for internal, rather than external, COI management. Apparent COIs within the Guideline Group and its leadership include positions of leadership in gender clinics, pursuit of leadership roles in WPATH’s European affiliate (EPATH), and, in at least one case, apparent ties to pharmaceutical companies that manufacture puberty blockers. 

Further, there is evidence that unmanaged COIs impacted the Guideline Group’s ability to be impartial. This is especially evident in how the Guidelines handled the discussion of divergent treatment recommendations for gender dysphoria in other European countries, with a specific focus on the Cass Review. The Cass Review is an independent review commissioned by NHS England which assessed the evidence and practices for youth gender transition in the UK. The Cass Review contributed to the UK’s recent shift toward caution in treating gender-dysphoric young people, restricting puberty blockers for gender dysphoria to clinical trials, and recommending a much more judicious approach to prescribing cross-sex hormones.

The Guidelines harshly criticized the Cass Review, drawing much of the argumentation from an infamous document which has become known as the “Yale” report (Yale University has clarified on multiple occasions that it does not take any responsibility for the report even though it is displayed on the Yale law school web page). As demonstrated in at least three analyses published in peer-reviewed journals, this  so-called “Yale” report contains a worrying level of misinformation, misunderstands the role and process of “independent reviews” (as opposed to treatment guidelines), and frequently resorts to ad hominem attacks. Further, it has come to light that the report has been produced by a group of paid expert witnesses for U.S. court cases specifically for use in court proceedings, rather than for a genuine scientific purpose. Debating any scientific document, including the Cass Review, is appropriate and welcome, but debate needs to be based on accurate facts. Further, it remains unclear whether the societies that voted for the adoption of the final guidelines had been provided with the full version that contained the criticisms of the Cass Review, or if they voted on a partial draft that omitted the section on the international changes, as appears to be the case.

After much debate and significant revision of the draft Guidelines, the final version of the Guidelines was officially adopted in March 2025 – a year after the original draft was released. However, two of the German medical societies involved in their development refused to sign the document, and several others issued alternative recommendations, which are included in an appendix to the Guidelines. Switzerland — another intended user of the Guidelines due to its German-speaking status—has yet to sign on as of March 2025, and has initiated its own additional review. 

Notwithstanding these dissenting opinions, the Guidelines have been accepted by most of the medical societies that participated in their development. This approval took place despite significant deviations from evidence-based guideline development procedures and other irregularities—such as a missing legal report dealing with the issues of informed consent, and apparently a missing chapter on diverging international recommendations, which is included in the published report but seems to have not been shared with all the societies prior to voting. It is questionable whether the busy boards of medical societies had the requisite time and expertise in guideline evaluation to adequately engage with the 555 pages of, at times, highly technical content contained in the two reports they approved.

That the German guidelines have finally been approved by most of the societies that participated in this arduous, years-long process—one that ended with a contentious round of revisions — likely reflects a state of collective exhaustion, a desire for unity, and a wish to move forward. While the final official approval of the Guidelines may help heal some internal divisions, it offers little consolation to gender-distressed adolescents and their families, whose care risks being driven by ideology rather than science and evidence, and who may receive life-altering interventions uninformed by, and in fact, often directly contradicted by, the best available evidence.

The situation in Germany is not unique. In response to the growing awareness of problems in the evidence base for youth gender transitions, several groups have produced methodologically-inadequate guidelines that continue to advocate for youth transitions, asserting that the guidelines' “consensus” status frees them from the responsibility to base their recommendations on the best available evidence. While consensus is a part of any guideline development, it can never be a substitute for an evidence-based process. 

Evidence-based guidelines explicitly allow for consideration of other factors besides the evidence, including the values and preferences of patients and their families. The key strength of an evidence-based guideline development methodology, besides the rigor, is its transparency: the resulting guidelines openly disclose the evidence underpinning the recommendations, assess how trustworthy that evidence is, and clearly describe other factors that influenced the recommendations. Such transparency enables guideline users—from children and parents to treating clinicians—to make genuinely informed treatment decisions. This is entirely missing from the “consensus” guidelines, which are usually created by groups of like-minded individuals in the style of “GOBSAT” (Good Old Boys Sat Around the Table).

It is difficult to see how the field of youth gender medicine will ever move beyond its current troubling state without recognizing that continued reliance on “consensus” guidelines is not a solution, but instead a core part of the problem. When "consensus" guidelines recommend highly invasive, life-altering and often irreversible interventions, yet fail to explain why such treatments are justified when the evidence does not support them — and when such non-evidence-based recommendations are then claimed to be the "standard of care" — top-down regulation in the form of bans and other restrictions is to be expected.  In countries and states that have not yet engaged in such regulation, a commitment to developing evidence-based guidelines would go a long way toward enabling a productive dialogue between professionals who deeply care about children and young people struggling with gender-related distress, but sharply disagree about how to help them.

Despite their formal adoption, it appears that the German Guidelines remain non-binding, leaving each clinician free to determine whether following their recommendations is prudent. A detailed analysis of the final adopted Guidelines is presented below.

1. Overview of the German AWMF “S2k” Guidelines

In March 2025, new clinical practice guidelines for the diagnosis and treatment of adolescent gender dysphoria and gender incongruence (Geschlechtsinkongruenz und Geschlechtsdysphorie im Kindes- und Jugendalter – Diagnostik und Behandlung) were approved by the Association of the Scientific Medical Societies in Germany (AWMF). These Guidelines are designed for use by clinicians in Germany, Austria, and Switzerland, but are non-binding.

The Guidelines failed to reach the originally-intended S3 “evidence-based” level and instead were certified as a lower level of “consensus-based” (S2k). The final approved version differs substantially from last year’s draft. The updates were made in response to serious criticism of the draft's methodology and recommendations, from within Germany and internationally, with the Society for Evidence Based Gender Medicine (SEGM) writing in depth about methodological problems in the prior draft. While the final adopted version addresses some, but not all, of the content criticisms, the majority of the methodological criticisms still apply. 

The final version of the Guidelines is substantially more cautious than the previously published draft, although it still represents a significant departure from the updated official policies in the UK, Sweden, Finland, and the growing number of countries that are abandoning the “affirmation” approach.

The original March 2024 draft of the Guidelines closely aligned with WPATH’s positions, which represent a radical departure from both the evidence base and the ethical principles of medicine. At the same time, even the original draft already deviated from WPATH’s approach by asserting that the ICD-11 diagnosis “gender incongruence” alone is insufficient to justify hormonal or surgical treatment. Instead, the Guidelines stipulated that a young person must also be experiencing significant distress alongside feelings of “incongruence.” This criterion for clinically significant distress has been retained in the final version. Recognition that a desire for body modifications alone does not constitute a valid target for clinical treatment serves as a tether to clinical reality—which seems absent from the ICD-11 diagnosis, itself an apparent product of political activism. 

Shortly after the publication of the March 2024 draft, significant debate arose, likely fueled by widespread public criticism—both within Germany and internationally. In response, the Guidelines were redrafted for approval in October 2024 and ultimately adopted in March 2025. The final version includes 79 recommendations across five topics, along with eight evidence statements. The recommendations are categorized based on their strength:

• ⁠Strong (soll/sollen; starke Empfehlung): 19 recommendations.

• ⁠Moderate (sollte/sollten; Empfehlung): 45 recommendations.

• ⁠Weak (kann/können; Empfehlung offen): 7 recommendations.

• 8 recommendations contain a pair of either Strong/Moderate statements, or Moderate/Weak statements.

The final text of the Guidelines has undergone substantive changes since the March 2024 draft. The strength of nine recommendations was modified, though no rationale was provided. Ignoring minor edits, 29 recommendations were changed, including the addition of six new recommendations and the removal of two. The table linked at the end of this Spotlight details these revisions. A close examination reveals significant disagreements surrounding the earlier draft and efforts to reconcile them in the final adopted version. Of particular concern, the process for grading the strength of recommendations remains opaque and appears to be disconnected from the actual strength of the evidence. For further discussion, see section 4 “Methodological Concerns” below.

A move toward caution—but deep problems remain

The most notable change in the new version of the Guidelines compared to the prior draft is the clear recognition that most young people with gender-related concerns likely experience temporary “gender non-contentedness” and should not undergo gender transition. The Guidelines now acknowledge the role of social influence in the rising prevalence of temporary transgender identification among minors and have revised their stance on “nonbinary” adolescents. Specifically, they now discourage the use of puberty blockers and categorically reject surgeries as treatment options for this group, though their position on cross-sex hormones remains less clear.

The new Guidelines also reversed the prior draft’s recommendation that psychological assessments could be skipped if the onset of puberty made transition feel “urgent.” The current version now requires psychological evaluations in all cases, regardless of perceived urgency, while recommending that such assessments be conducted promptly. Additionally, the Guidelines strengthened their recommendation to inform parents of socially transitioned children about the possibility of later detransition, upgrading it from “moderate” to “strong.”

However, despite this welcome shift toward greater caution, the Guidelines remain fundamentally untrustworthy because their recommendations are not evidence-based. They also lack clinical utility, offering no guidance on how to differentiate between temporary “gender non-contentedness,” which should not lead to medical intervention, and cases of persistent transgender identity, considered by the Guidelines as candidates for medical and surgical transition.

2. Treatment Recommendations

The final version of the Guidelines includes a stronger emphasis on the benefits of differential diagnosis, and the need to distinguish between the transient forms of “gender non-contentedness” (Gender-Unzufriedenheit, p. 26) and the “stable/persistent” (stabilen/persistierenden) gender incongruence in young people. The Guidelines assert that in minors, only the stable/persistent gender incongruence should be addressed with hormones and surgery. 

The Guidelines acknowledge the following important points relating to assessment of gender-dysphoric youth:

• Assessments cannot be skipped. The final draft of the Guidelines reinstates the need for assessment regardless of the urgency expressed by the patient or family. 

• Differential diagnosis is helpful. “A differential diagnosis must also consider the possibility that, particularly when a diagnosis of stable or persistent gender incongruence or gender dysphoria cannot yet be established with sufficient certainty in an adolescent, other psychological issues may contribute to temporary gender dissatisfaction accompanied by gender dysphoric symptoms. [Auch ist differentialdiagnostisch die Möglichkeit zu bedenken, dass, insbesondere so lange bei einer jugendlichen Person die Diagnose einer stabilen/persistierenden Geschlechtsinkongruenz bzw. Geschlechtsdysphorie noch nicht mit hinreichender Sicherheit gestellt werden kann, anderweitige psychische Probleme zu einer vorübergehenden Gender-Unzufriedenheit mit geschlechtsdysphorischen Symptomen führen können]”, p. 74. The Guidelines also discuss the potential role and influence of autism spectrum disorder (ASD) on transgender identification (pp. 81–4), although there is no clear guidance on how clinicians should interpret or act upon such a finding as it relates to an adolescent’s wish to undergo medical transition.

• Gender-related concerns in youth are common. The Guidelines observe that gender non-contentedness is both widespread and common in early adolescence (“ein weit verbreitetes Phänomen im Jugendalter ist,” p. 51; “ein häufiges Phänomen im frühen Jugendalter,” p. 53). The Guidelines also acknowledge that this experience sometimes extends into adulthood (p. 26). They state that gender non-contentedness may present “with gender dysphoria-like symptoms [mit geschlechtsdysphorie-ähnlicher Symptomatik],” p. 196, and lead young people to “self-identify as transgender [Selbstbeschreibung von jungen Menschen als trans],” p. 100. 

• Youth with temporary gender distress far outnumber those for whom such distress will be permanent. The Guidelines acknowledge that the number of youths with temporary transgender identification is significantly larger than those with persistent feelings of gender incongruence, the latter constituting only “a small fraction of the reported frequencies of gender dissatisfaction [eines kleinen Bruchteils der berichteten Häufigkeiten von Gender-Unzufriedenheit liegen dürfte],” p. 51 and are “much rarer [deutlich seltenere]”, p. 100.

• There is no established way to identify those for whom gender dysphoria will persist long-term. The Guidelines acknowledge that “empirically validated individual criteria for the determination of permanent stability/persistence of gender incongruence or gender dysphoria are not available according to the studies we reviewed [Empirisch validierte Einzelkriterien für die Feststellung einer dauerhaften Stabilität/Persistenz der Geschlechtsinkongruenz bzw. Geschlechtsdysphorie liegen nach der von uns gesichteten Studienlage nicht vor],” p. 188. 

• Peer influence and social media content may lead to adolescents self-reporting as transgender. The Guidelines acknowledge that peer influence may lead to “a temporary self-description as transgender, particularly when influenced by other psychopathological abnormalities, peer groups, or social media [kann in Verbindung mit weiteren psychopathologischen Auffälligkeiten sowie mit Einflüssen aus Peer-Group oder sozialen Medien],” p. 100. 

• Distress associated with incongruence is required as a prerequisite for medical interventions. Although the Guidelines state that the provision of the ICD-11 “gender incongruence” diagnosis (ICD-11 eliminated the “distress” criterion) is a sufficient outcome of assessment, and the dual diagnosis of DSM-5 “gender dysphoria” (which requires the presence of distress) is unnecessary (p. 184), eligibility for medical and surgical interventions does require the presence of concomitant distress.

• Youth with temporary transgender identification should not undergo medical transition. The Guidelines emphasize that youth with temporary gender distress “must be distinguished from the specific and much rarer constellation of persistent gender incongruence with gender dysphoric distress [Davon abzugrenzen ist die spezifische und deutlich seltenere Konstellation einer persistierenden Geschlechtsinkongruenz mit geschlechtsdysphorischem Leidensdruck]”, p. 100. The three central recommendations for initiating puberty blockers, cross-sex hormones, and breast surgery (recommendations VII.K3, VII.K14, VII.K25) explicitly limit these interventions to cases assessed as stable or persistent.

  
  

Gender non-contentedness 

Unfortunately, the Guidelines’ key assumption that “gender non-contentedness” and “stable/persistent” gender distress are mutually exclusive is contradicted by the evidence. The term “gender non-contentedness” was popularized following an important 2023 publication by Rawee et al. that the Guidelines discuss (p. 50). This study found that gender non-contentedness is common in childhood and adolescence and naturally resolves by early adulthood in the vast majority of cases. 

Notably, Rawee et al. classified individuals experiencing “gender non-contentedness” based on their affirmative response to the Youth Self Report/Adult Self Report (YSR/ASR) questionnaire item 110: “Wishes to be the opposite sex.” However, this response does not distinguish between youth who are merely unhappy with their gender and those meeting the clinical diagnostic threshold for gender dysphoria or gender incongruence. In fact, studies have demonstrated that item 110 is frequently used as a broad proxy for the clinical diagnosis itself, as it captures a key criterion: the desire to be the opposite sex. It was the instrument used to determine the onset age of gender dysphoria in a 2025 paper examining adolescents attending a gender clinic in Germany. Further, while Rawee et al. showed that the majority of youth with “gender non-contentedness” eventually reconcile with their sex, approximately 2% of respondents still wished to be the opposite sex by age 22, underscoring that “gender non-contentedness” can coexist with “stable/persistent” gender dysphoria/incongruence, and that the two characteristics are not mutually exclusive.

The Guidelines stop short of explaining how clinicians are to differentiate long-lasting “gender non-contentedness” from “stable/persistent” cases of gender incongruence, particularly since, as noted in several places, these two categories can present very similarly. Instead, the Guidelines offer circular reasoning that cases diagnosed with the DSM diagnosis of “gender dysphoria” or the ICD-11 diagnosis of “gender incongruence” are, by definition, “stable/persistent.” This approach lacks face validity, however, since the DSM diagnosis of gender dysphoria for adolescents requires only six months of symptoms, while the ICD-11 diagnosis of gender incongruence in adolescence has no minimum duration criterion. 

In addition, the Guidelines ignore several studies—including one from Germany—that have demonstrated that the diagnostic stability of gender-related diagnoses in adolescents is very low. The 2024 German study found that after 5 years, only 36.4% of young people retained a gender identity-related diagnosis in their medical records, with adolescent females aged 15–19 exhibiting the lowest persistence rate (27.3%). Another 2023 study, published in the BMJ, reached a similar conclusion, finding that gender dysphoria in youth is not a permanent diagnosis. 

In summary, the Guidelines accurately state that only a “small proportion [kleinen Bruchteils]” (p. 51) of young people endorsing item 110—”wishing to be the opposite sex”—go on to develop stable/persistent gender incongruence by early adulthood; they sensibly advise that only those with stable/persistent distress should be candidates for medical transition; and correctly acknowledge that there is no way to predict which young people will remain trans-identified long term. 

Thus, by their own logic, the Guidelines should have recommended applying the precautionary principle—which is to treat presenting youth with non-invasive treatments such as psychotherapy—while reserving medical transition for adulthood when it is clearer whether the distress is likely to be long-lasting or even permanent. Instead, the Guidelines proceed to recommend allowing access to puberty blockers, cross-sex hormones, and surgery to minors who assert a transgender identity, with no explanation about how to address concerns about the impermanence of such identities in adolescence raised in their discussion. 

In addition, adolescents who identify as non-binary should not receive puberty blockers ([benötigen nur in sehr seltenen Ausnahmefällen eine pubertätsblockierende Behandlung, p. 192]) and are barred from undergoing breast surgery before age 18 [Dennoch kann derzeit für Jugendliche mit non-binärer Identität unter 18 Jahren derzeit keine Leitlinienempfehlung für brustchirurgische Eingriffe gegeben werden, p. 229]. The Guidelines’ stance toward cross-sex hormones for non-binary youth is unclear.

The treatment recommendations acknowledge other important points, including the following: 

• Most children given puberty blockers continue with further medical transition. The Guidelines acknowledge that “The vast majority of adolescents who receive puberty blockade later continue their transition with gender reassignment hormone treatment [überwiegende Mehrzahl der Jugendlichen, die eine Pubertätsblockade erhalten, ihre Transition später mit einer geschlechtsangleichenden Hormonbehandlung fortsetzen],” p. 163.

• Infertility is acknowledged as a certain side effect of the treatment protocol. The Guidelines note that initiating puberty blockers at Tanner Stage 2, followed by cross-sex hormones, typically leads to infertility (“If puberty suppression with GnRH analogs is initiated in the early stages of puberty and is later followed directly by sex reassignment hormone treatment, it usually results in permanent infertility due to the failure of the gonads and reproductive tract to mature [Erfolgt eine Pubertätssuppression mittels GNRH-Analoga in einem frühen Pubertätsstadium, ist im Falle einer sich später nahtlos anschließenden geschlechtsangleichenden Hormonbehandlung meist eine dauerhafte Infertilität aufgrund ausbleibender Ausreifung der Gonaden und des Reproduktionstrakts die Folge],” p. 243).

• Regret or desistance are explicitly acknowledged as possible outcomes. There is clear acknowledgment that a percentage of young people regret their medical interventions. The Guidelines discuss the importance of safeguarding “the child’s right to an open future [Recht des Kindes auf eine offene Zukunft],” pp. 63, 285. The German constitution explicitly protects the child's objective right to physical integrity. However, the Guidelines also highlight subjective rights, such as quality of life and reduced suffering, while equivocating on how to reconcile the two.

Despite these changes, the Guidelines effectively allow widespread application of gender transition to all minors as long as they report being distressed by “long-lasting” cross-sex transgender identities. The following is a synthesis of the recommendations regarding social transition, puberty blockers, cross-sex hormones, and surgery.

Social transition

The Guidelines portray social gender transition (SGT) among prepubertal children as beneficial and low-risk—although the final version increased the strength of the recommendation to advise parents about the possibility of subsequent detransition.

The evidence cited in support of social transition, however, is not evaluated using best practices: it is not systematically searched, the studies are not assessed for risk of bias, and the body of evidence is not evaluated for certainty using GRADE. As a result, the Guidelines rely on a skewed evidence base, favoring evidence that appears supportive of social transition, while ignoring evidence that contradicts this approach.

• The discussion emphasizes an American study by Olson et al. (2022) as positive evidence that early SGT is a safe practice due to the high rates of continued cross-sex identification of socially-transitioned minors. The authors fail to discuss an alternative explanation for the study findings—that early social transition might itself reinforce a transgender identity. 

• The Guidelines entirely overlook a key German study by Sievert et al. (2021) that contradicts the Guidelines’ stance toward social transition as beneficial. This study found that “not social transition status, but peer relations and family functioning predict psychological functioning in a German clinical sample of children with Gender Dysphoria.” 

• We direct readers to the York systematic review on social transition, which found the evidence of psychological benefits of SGT thoroughly lacking—a finding that the Guidelines failed to properly engage with.

  
  

Puberty blockers

The Guidelines acknowledge significant uncertainties about puberty blockers, including risks and long-term impacts, specifically acknowledging the following:

• Initiation at Tanner Stage 2 may result in sterility (p. 243).

• Puberty blockers have negative effects on bone health: (“What the studies have in common is that a statistically significant decrease in absolute bone density was observed following puberty blockade [Gemeinsam ist den Studien, dass eine statistisch signifikante Abnahme der absoluten Knochendichte nach erfolgter Pubertätsblockade zu beobachten war],” p. 247).

• The vast majority of adolescents who begin puberty blockers proceed to cross-sex hormones (p. 163).

However, intervention with puberty blockers is described as beneficial overall, and as fully reversible. The evidence cited in support of this position is not evaluated using best practices: it is not systematically searched, the studies are not assessed for risk of bias, and the body of evidence is not evaluated for certainty using GRADE. As a result, the Guidelines rely on a skewed evidence base, favoring evidence that appears supportive of puberty blockers, while ignoring evidence that contradicts this approach.

• The Guidelines positively describe studies such as de Vries (2011), despite their known severe limitations.

• The Guidelines overlook recent studies that cast doubt on the benefits of puberty blockers, such as Carmichael et al. (2021) and McPherson & Freedman (2023). These studies do not support the notion that puberty blockade is beneficial and introduce the possibility that as many as one third of children may experience psychological deterioration while taking puberty blockers.

• We direct readers to systematic reviews of the literature, including NICE 2020 on puberty blockers, Zepf 2024, York 2024 on puberty blockers, and McMaster 2025 on puberty blockers, which uniformly conclude that the evidence of psychological benefits of puberty blockers is of very low certainty—a finding that the Guidelines failed to properly engage with.

  
  

Cross-sex hormones (CSH)

The Guidelines emphasize that initiating CSH should only occur when adolescents demonstrate stable, persistent gender incongruence with associated distress lasting several years after the onset of puberty. The Guidelines acknowledge several risks of cross-sex hormones, including: 

• Significant risk of harm to fertility

• Increased thrombosis risk

• Problematic changes in BMI, which may increase future health risks

Despite these risks and uncertainties, CSH are recommended as beneficial. The evidence cited in support of this position is not evaluated using best practices: it is not systematically searched, the studies are not assessed for risk of bias, and the body of evidence is not evaluated for certainty using GRADE. As a result, the Guidelines rely on a skewed evidence base, favoring evidence that appears to support cross-sex hormones, while ignoring evidence that contradicts this approach. 

To select two examples from many where significant shortcomings in studies are overlooked: papers by Tordoff et al, 2022 and Chen et al., 2023 are cited.

The Guidelines positively reference Tordoff et al., 2022 for its reported marked improvement in mental health following the administration of endocrine interventions for gender dysphoria. They do not mention, however, the well-known and profound methodological limitations of this study—including the fact that despite the study’s claims, depression rates remained unchanged before and after treatment. Further, Tordoff et al. lost a remarkable 80% of their untreated participants who served as the “control” group by the end of the study, which entirely invalidated the study's conclusions.

Chen et al. 2023 is described as finding lower levels of anxiety and depression two years after the start of hormone treatment, with the treated group reporting higher life satisfaction. However, the Guidelines fail to properly engage with the many methodological problems in the study. They also do not mention that natal males did not experience any improvements, and they overlook the unacceptably high number of suicides that tragically took place within the participant group within just one year of starting treatment. 

We direct readers to systematic reviews of the literature, including NICE 2020 on CSH, Sweden 2023, Zepf 2024, York 2024 on CSH, McMaster 2025 on CSH, which uniformly conclude that the evidence of psychological benefits of CSH is of very low certainty—a finding the Guidelines failed to properly engage with. We note that the Guidelines misrepresent findings from the UK NICE review as providing evidence of the benefits of CSH treatments. Instead, the UK NICE reviews highlighted the very low-certainty evidence supporting the use of CSH in adolescents.

Surgery

The Guidelines’ recommendations for “gender-affirming” surgery for people under age 18 are restricted to mastectomies or surgical breast reduction; genital surgeries are not recommended until after 18. As with CSH, the Guidelines state that adolescents must exhibit stable/persistent gender incongruence for several years (“dauerhaft persistierenden Geschlechtsinkongruenz nach einer vollständig vollzogenen Transition bereits seit mehreren Jahren”, and have significant body-related distress (“ausgeprägtem geschlechtsdysphorischem Leidensdruck und entsprechendem Behandlungswunsch”, p. 224).

The Guidelines acknowledge the risks of providing irreversible interventions such as mastectomy to minors and include a new recommendation, VII.K25a, to document the risk-benefit assessment for performing mastectomies before age 18 versus waiting until the age of majority. However, despite this acknowledgment, mastectomies are allowed with no minimum age specified and with only minimal safeguarding.

• The Guidelines explicitly do not mandate prior hormone therapy or psychotherapy as prerequisites.

• Although a risk-benefit assessment is recommended, a comprehensive mental health evaluation is encouraged but not mandated. Further, no proof of adequate treatment for co-occurring mental health conditions is required.

• The recommendation for a six-month waiting period after initiating hormone treatment, which was included in the March 2024 draft, has been removed. Additionally, mastectomies may now be performed on adolescents who have not yet begun testosterone treatment. 

Like the critique of other “gender-affirming” treatments recommended by the Guidelines, the evidence cited in support of the use of breast surgery in minors is not evaluated using best practices: it is not systematically searched, the studies are not assessed for risk of bias, and the body of evidence is not evaluated for certainty using GRADE.

As a result, the Guidelines rely on a skewed evidence base (citing only four studies with young people who received mastectomies or wished to do so) and describe the results as supportive of surgery—despite the significant problems in the studies. The Guidelines also disregard a recent systematic review of evidence that arrived at a markedly different conclusion: very low certainty of benefit and high certainty of harm. 

• The four cited studies are presented as positive, despite their critical risk of bias (which would be evident had the studies been subjected to a risk of bias assessment, as was done in a recent systematic review). 

• In contrast to this positive appraisal of mastectomies for minors, we direct readers to a 2024 systematic review evaluating studies on mastectomies for gender dysphoric young people. This systematic review found that all studies evaluating quality of life, depression, body satisfaction, and chest satisfaction were of low to very low certainty, while the evidence of harm is of high certainty.

• The failure to demonstrate that mastectomies in minors result in positive outcomes—and the certainty of harm—would be the reasons to consider delaying surgery until the age of majority, a more typical time for such procedures in much of Europe (e.g., the UK, Finland, Sweden).

3. Evidence of bias and other irregularitiesHeavy reliance on WPATH’s positions

The final version states that the Guideline Group members “predominantly share the views of the current international guidelines of the Endocrine Society (Hembree et al., 2017) and the World Professional Association for Transgender Health (WPATH) (Coleman et al., 2022) [überwiegend die Auffassungen der aktuellen internationalen Leitlinien der Endocrine Society sowie der World Professional Association for Transgender Health],” p. 222. Societies that did not agree with this position or with the final document include the German Society for Sexual Medicine and Sexual Psychology (DGSMTW; now the German Society for Social Medicine and Prevention, DGSMP) and the German Society of Urology (GDU), Guideline Report, pp. 3, 28. 

The reliance on WPATH is apparent. WPATH’s Standards of Care, version 8 (SOC8) is cited over 45 times. Indeed, some passages of the Guidelines follow SOC8 closely enough to raise concerns over the document’s management of quality control and whether it has followed “the highest possible scientific standards” as AWMF expects (AWMF Guidance Manual, p. 5). We invite readers to compare, for example, pp. 8–11 of the German Guidelines with pp. 23–25 from SOC8 in Table 1 at the end of this Spotlight. Some text from this table is presented here as well: yellow highlighting indicates similar text and blue highlighting indicates a citation appearing in identical order in both texts (in the Guidelines this is every citation). Red highlighting indicates an error in the Guidelines.

Additional evidence of COIs and questionable management of COI

There are numerous other apparent conflicts of interest, including: 

• Most of the authors have substantial clinical or scientific involvement in promoting the practice of gender transitions (Guideline report, App. E)

• The head of the committee, Dr. Georg Romer, leads a pediatric gender clinic and is a contender for the director at large position at WPATH’s European branch EPATH.

• Another member, Dr. Richter-Unruh, for a decade (2013–2023) held university positions endowed by Ferring Pharmaceuticals, a Swiss company that manufactures and markets puberty blockers. She now leads EMPOWER-TRANS*, a digital platform aimed at providing information to transgender children and adolescents to streamline face-to-face appointments and process more minors. This initiative is partnered with Bundesverband Trans* and Trans*-Kinder-Netz (TraKiNe), two advocacy organizations that also contributed to and influenced the content of the Guidelines. The project is funded with €4.9 million from Germany’s statutory health insurance (Gesetzliche Krankenversicherung), but this funding has not been declared.

COIs in this area of medicine are common and often unavoidable. While the AWMF recommends that the best practice is for a third party to manage the COI process, it does not require it (AWMF Guidance Manual, p. 29). Given the significant COIs identified above, however, it would have been more prudent to follow a best practice protocol by appointing a third party to manage these conflicts. As it stands, current COIs, including undisclosed issues, raise questions about the credibility of the COI management process. 

Biased assessment of the Cass Review 

The Guideline Group’s failure to impartially and objectively engage with the evidence is exemplified by the Guidelines’ appraisal of the Cass Review: a four-year robust evaluation of youth gender medicine in the UK.

The Guidelines based their harsh criticism of the Cass Review on the widely discredited, non-peer-reviewed “Yale” analysis written by a highly conflicted group of American activists for legal purposes. The Guidelines further erred by wrongly evaluating the Cass Review with criteria meant to assess clinical practice guidelines (CPGs), rather than independent reviews. This fundamental category error—mistaking the Cass Review for a CPG—renders their critique invalid.

Among the many misguided criticisms of the Cass Review, the Guidelines appear to reprimand the Cass Review for inadequately incorporating population-representative data (p. 14), subsequently dedicating several pages to discussing transgender-related questions from the 2021 UK census. However, the Guideline Group appears unaware that the UK Office for National Statistics explicitly cautioned that the responses to this particular census question should not be considered accredited official statistics. This has been explained in a research paper published in a peer-reviewed journal. 

Other irregularities

The primary document used to support the Guidelines' legal views on child and adolescent consent—cited 14 times and frequently quoted—is an unpublished, non-peer-reviewed report prepared by Thomas Gutmann for Münster University Hospital in 2023. As this document has not been made publicly available, and reports indicate that attempts to review it have been refused, this lack of transparency and accountability is concerning. It also falls short of the standards clearly outlined in the AWMF Guidance Manual (p. 5), which emphasize the value of transparency in guideline development.

Further, it appears that the Appendix: Diverging National Recommendations (Anhang – Divergierende nationale Empfehlungen), from page 319 onward, may have been missing from the version of the Guidelines presented to a number of the medical societies for their final vote. This appendix, which appears in the final published version, was referenced at least six times within the draft of the Guidelines. If true, the omission of this important appendix (which also included the Cass Review criticism) from the version accepted by medical societies would raise new doubts about the validity of the Guidelines’ adoption. (The accuracy of this assertion should be verified by the Boards of the medical societies that voted on the Guidelines, as SEGM does not have full transparency into the process.) 

The Guideline Report notes that all the participating specialist societies were given only a four-week window to provide comments: for such a lengthy and complex document, this time was inadequate, resulting in a document that did not have the opportunity to be properly scrutinized. Even with this limited time frame, 15 members of the DGKJP managed to submit a 111-page critique of the Guidelines. 

4. Methodological concerns

The vast majority of the methodological concerns outlined by SEGM last year in response to the earlier draft Guidelines remain unaddressed. Chief among these is that the recommendations relied in part on selectively chosen individual studies taken from WPATH's SOC8, rather than being grounded in an independent systematic evidence review (WPATH later suppressed publication of its own systematic evidence reviews). 

While reliance on WPATH evidence evaluation was transparently presented in the prior draft of the Guidelines, the final version now downplays this fact, likely in response to the growing awareness of problems with WPATH’s evidence suppression. The final accepted version has now added three recent systematic reviews of evidence (Guideline report, p. 22). However, it is apparent that while the existence of these systematic reviews has now been acknowledged, the information they contain has not been used to influence recommendations.

An instructive example of this disparity between the systematic reviews cited in the Guidelines and the formal recommendations is Evidence Statement VII.E1. This particular statement is especially important, as it underpins several of the most clinically significant recommendations in Chapter 7.

This statement (reproduced below) asserts that puberty blockers, cross-sex hormones, and surgery lead to long-term improvements in mental health and quality of life (p. 156). However, this statement is followed by a reference to three individual studies, rather than systematic reviews of evidence, as would be expected in an evidence-based guideline. Notably, these studies—originating from the Dutch gender clinic—have all been subjected to substantial methodological criticism in the peer-reviewed literature. 

In contrast to these three studies’ favorable appraisal of the results of puberty blockers, cross-sex hormones, and surgeries, all the systematic reviews, including those referenced by the Guidelines, have concluded that the evidence is of “low” or even “very low certainty.” Using GRADE terminology, this indicates that the results reported by the studies are unlikely to represent the truth. Had the authors properly considered these systematic reviews, Evidence Statement VII.E1 asserting the benefits could not have been made. 

We also note that in the previously released draft, Evidence Statement VII.E1 had the lowest consensus of any Evidence Statement (75%). Inexplicably, the final published version omits any reference to the consensus level for this statement—and according to our analysis remains the only statement in the entire Guidelines that is missing a listed percent of consensus, which is a requirement for S2k AWMF level certification. According to media reports, this statement was a particular source of contention within the consensus process, with the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) wishing it removed altogether (App. A, p. 25).

• Note: the above screenshot is from the machine-translation of the German Guidelines. The official AWMF translation is not yet available.

5. German and international criticisms

When the draft Guidelines were released in March 2024, they immediately faced intense criticism domestically and internationally, including explicit rejection by the German Society for Psychiatry (DGPPN) and the German Society for Sexual Medicine, Sexual Therapy, and Sexual Science (DGSMSP). The preamble in the final Guidelines was rejected in its entirety (Guideline Report, p. 24) by the German Association for Psychiatry, Psychotherapy, Psychosomatics, and Neurology, Germany's largest scientific medical association focusing on mental health (DGPPN).

Following the updates to the Guidelines described above, most societies chose to accept them, but two—the German Society for Urology and the German Society for Sexual Medicine and Sexual Psychology (DGSMP)—rejected them outright. Others, including DGPPN and several prominent Chairs of the German Society for Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy (DGKJP), expressed reservations. Additionally, several societies issued alternative or special recommendations within the Guidelines, recorded in Appendix A.

Further, the Guidelines failed to secure Switzerland’s endorsement at the time of this writing, with many members unable to meaningfully participate as the document was disseminated only in German and not in Switzerland’s other two official languages, French and Italian. However, the Swiss Society for Child and Adolescent Psychiatry was able to express reservations (see Guideline Report, App. F.). Switzerland appears be undertaking additional review of the Guidelines recommendations, following concerns raised about the Guidelines’ credibility. 

SEGM take-away

The German Guidelines’ acknowledgement that most youth presenting with gender-related distress should not undergo medical transition is a welcome recognition of reality that is increasingly acknowledged throughout the Western world. However, this creates a conundrum for the field. Without a clear, prospective method to distinguish between “gender non-contentedness,” which the Guidelines insist should not be treated with transition, and “stable/persistent” gender incongruence, which the Guidelines assert can be safely medically transitioned, the most reasonable and cautious assumption for medical practitioners is that most young people presenting with gender-dysphoric or gender-incongruent symptoms are more likely to fall into the transient rather than stable/persistent category. Instead, the Guidelines effectively create a path for ongoing gender transitions for the majority of adolescents who desire them.

Germany is not unique in facing this conundrum, and the publication of these Guidelines exemplifies the state of disarray in which the field of gender medicine finds itself throughout the Western world.

On the one hand, there is now widespread recognition among good-faith actors, including some who practice youth gender medicine, that the best available evidence does not support claims of the psychological benefits of “gender-affirming” practices. There is also growing acknowledgment of the direct harm these interventions cause to many young people, a reality that is becoming increasingly difficult to ignore.

On the other hand, advocates for these practices continue to insist that youth gender transitions should continue—so long as clinicians exercise “caution” and work within “multidisciplinary” teams. However, there is little practical guidance on what this “caution” actually entails, effectively permitting “multidisciplinary” teams of gender-affirming psychologists, psychiatrists, and endocrinologists to continue with the status quo. 

Against the backdrop of a clear recognition of problems in the evidence, those promoting youth transitions have begun to rely on creating new guidelines which they label as “consensus” guidelines. This label, on the surface, seemingly allows guidelines to bypass a rigorous process of developing evidence-based guidelines and instead favors the outdated approach humorously known as “GOBSAT” (Good Old Boys Sat Around the Table). In the past year alone, several groups of gender-affirming clinicians have released such guidelines, including the ESPE guidelines, the French Endocrinology guidelines, the Polish guidelines, and the as yet unpublished French HAS guidelines.

All these guidelines demonstrably contravene key principles of evidence-based guideline development. Meanwhile, their authors assert they are not bound by these standards because their guidelines are merely based on “consensus.” 

It is difficult to envision how the field will move beyond its current troubling state without recognizing that continued reliance on “consensus” guidelines is not the solution, but is itself the problem. Until there is a shared commitment to developing true evidence-based guidelines, youth gender medicine will remain deeply polarized.

Links

German Society for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy (DGKJP). AWMF-Leitlinie: Geschlechtsinkongruenz und Geschlechtsdysphorie im Kindes- und Jugendalter: Diagnostik und Behandlung (S2k) [AWMF Guideline: Gender incongruence and gender dysphoria in childhood and adolescence: diagnosis and treatment]. AWMF Registry No. 028-014. Version 1.0, 2025. https://register.awmf.org/assets/guidelines/028-014l_S2k_Geschlechtsinkongruenz-Geschlechtsdysphorie-Kinder-Jugendliche-Diagnostik-Behandlung_2025-03_1.pdf [referred in this text as Guidelines]

German Society for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy (DGKJP), Leitlinienreport, 2025. https://register.awmf.org/assets/guidelines/028-014m_S2k_Geschlechtsinkongruenz-Geschlechtsdysphorie-Kinder-Jugendliche-Diagnostik-Behandlung_2025-03.pdf [referred in this text as Guidelines report]

Association of the Scientific Medical Societies in Germany (AWMF) – Standing Guidelines Commission. (2023). AWMF guidance manual and rules for guideline development (Version 2.1). Retrieved [March 17, 2025], from https://www.awmf.org/fileadmin/user_upload/dateien/downloads_regelwerk/en_20230905_AWMF-Regelwerk_2023_V2.1.pdf [referred in this text as AWMF Guidance Manual]

A German translation of this Spotlight is available here, courtesy of Transteens Sorge berechtigt. We have not verified it for accuracy.

Table 1

Green highlight: similar/same text (in translation) as SOC8, with citation

Yellow highlight: similar/same text (in translation) as SOC8, without citation

Blue highlight: all references

Red highlight: error in Guidelines; corresponding red in WPATH is correct

This literature review from the Guidelines follows in its entirety the same order as SOC8. The summaries of every referenced study appear to be taken from SOC8, rather than from an independent review of the studies themselves.

• Every single cited reference in the Guidelines is identical to the corresponding text in SOC8 and is discussed in the same order as SOC8.

• At least one reference cited in the Guidelines' text (e.g., Adams et al., 2017) is missing from their bibliography, further suggesting the in-text references were taken from SOC8.

• Alongside reproducing SOC8’s review work, its final paragraph cites the same statistics WPATH developed as part of their overall analysis, without attribution. In the Guidelines this paragraph appears in a call-out box, highlighting its importance.