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En este artículo se reflexiona sobre la reciente ley aprobada por el Congreso de los Diputados conocida como Ley 4/2023 para la igualdad real y efectiva de las personas trans y para la garantía de los derechos de las personas LGTBI (BOE-A-2023-5366, 2023). Se analizan inicialmente los artículos que más polémica han causado en el ámbito social, que son los relativos a la rectificación registral (Art. 43-51), y posteriormente los que hacen referencia directa o indirectamente a aspectos sanitarios; 1) el que prohíbe de métodos, programas o las llamadas terapias de conversión (Art. 17), 2) los que definen cómo debe ser en términos generales la atención sanitaria (Art. 56-59), y 3) finalmente el único artículo que menciona a los menores (Art 70). Se comenta que el término utilizado de persona trans, al englobar un amplio abanico de diversidades sexuales, variantes y expresiones de género, incluye tanto a personas que necesitan una atención médica como a otras que no. Se plantea que la rectificación registral acorde con esta ley 2023 al no precisar ningún requisito para su inscripción, ofrece menos garantías que la legislación ya existente de marzo 2007. Se considera que las directrices de la nueva ley se están traduciendo en una toma de decisiones por parte del usuario sin disponer de una valoración o diagnóstico por el equipo de profesionales que atienden el caso. Se destaca que la ley no incluye ninguna referencia a la atención por salud mental. Y en conjunto, se concluye que el texto aprobado, en el ámbito sanitario, puede mermar la calidad de la asistencia integral, sobre todo en menores, o personas con identidades complejas, dudosas, o con comorbilidades, que pueden generar discrepancia entre el criterio del profesional y la opinión del usuario.(AU)

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Introducción. La destransición de género es el acto de detenero revertir los cambios sociales, médicos y/o administrativos conseguidos durante un proceso de transición de género. Se trata de un fenómeno emergente de gran interés a nivel clínico y social. Método. Se condujo una búsqueda sistemática en siete bases de datos entre 2010 y 2022, se rastrearon manualmente las referencias de los artículos y se consultaron libros especializados. Se realizó un análisis cuantitativo y de contenido. Resultados. Se incluyeron 138 registros, 37% correspondientes a estudios empíricos y 38,4% publicados en 2021. Se identifican al menos ocho términos para hacer referencia a la destransición, con diferencias en sus definiciones. La prevalencia difiere en función del criterio utilizado, siendo menor para la destransición/arrepentimiento (0-13,1%) que para la descontinuación de la asistencia/tratamiento médico (1,9%-29,8%),y menor para la destransición/arrepentimiento tras cirugía (0-2,4%) que para la destransición/arrepentimiento tras tratamiento hormonal (0-9,8%). Se describen más de 50 factores psicológicos, médicos y socioculturales que influyen en la decisión de destransicionar, así como 16 factores predictores/asociados a la destransición. No se encuentran guías de abordaje sanitario ni legislativo. Los debates actuales se centran en los interrogantes sobre la naturaleza de la disforia de género y el desarrollo de la identidad, el papel de los profesionales con respecto al acceso a los tratamientos médicos y el impacto de las destransiciones sobre la futura accesibilidad a dichos tratamientos. Conclusiones. La destransición de género es una realidad compleja, heterogénea, poco estudiada y escasamente comprendida. Se requiere un abordaje y estudio sistemático que permita comprender su prevalencia real, implicaciones y manejo a nivel sanitario. (AU)

Introduction. Gender detransition is the act of stoppingor reversing the social, medical, and/or administrative changesachieved during a gender transition process. It is an emergingphenomenon of significant clinical and social interest.Methods. We systematically searched seven databasesbetween 2010 and 2022, manually traced article references,and consulted specialized books. Quantitative and contentanalyses were carried out.Results. We included 138 registers, 37% of which were empirical studies and 38.4% of which were published in 2021. Atleast eight terms related to detransition were identified, withdifferences in their definitions. Prevalence estimates differ according to the criteria used, being lower for detransition/regret (0-13.1%) than for discontinuation of care/medical treatment (1.9%-29.8%), and for detransition/regret after surgery(0-2.4%) than for detransition/regret after hormonal treatment (0-9.8%). More than 50 psychological, medical, and sociocultural factors influencing the decision to detransition and16 predictors/associated factors are described. No health orlegal guidelines are found. Current debates focus on the nature of gender dysphoria and identity development, the role ofprofessionals in accessing medical treatments, and the impactof detransition on future access to these treatments.Conclusions. Gender detransition is a complex, heterogeneous, under-researched, and poorly understood reality. Asystematic study and approach to the topic is needed to understand its prevalence, implications, and management from a healthcare perspective. (AU)

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Estamos asistiendo estos últimos años a nivel mundial a un fenómeno similar al que hemos vivido en otras ocasiones; a la explosión de casos de menores con problemas psíquicos, traumas, dificultades de relación social, trastornos del espectro autista y otros trastornos mentales que se manifiestan bajo el paraguas de lo trans. Ante ese fenómeno, lo que dicta la buena práctica clínica es prudencia y paciencia, precisamente todo lo contrario a precipitarse a llevar a cabo procedimientos irreversibles como se está pregonando por parte de movimientos que pretenden perpetuar las diferencias de género y confunden el sexo biológico con la identidad de género, en un ataque sin precedentes a los pilares del feminismo y de las realidades científicas. Las sociedades deben proteger a sus menores de decisiones que, por su estado madurativo, tienen tendencia a realizar de manera más impulsiva y menos reflexiva, con mayores dificultades para evaluar riesgos y beneficios o alternativas que esas mismas personas con mayor madurez. Por eso no les dejamos que compren cigarrillos o alcohol o que conduzcan hasta que no tienen dieciocho años (AU)

In recent years we are witnessing a phenomenon similar to the one we have experienced on other occasions worldwide; to the explosion of cases of minors with psychological problems, traumas, social relationship difficulties, autism spectrum disorders and other mental disorders that manifest themselves under the umbrella of trans.Given this phenomenon, what good clinical practice dictates is prudence and patience, precisely the opposite of rushing to carry out irreversible procedures as is being proclaimed by movements that seek to perpetuate gender differences and confuse biological sex with gender identity, in an unprecedented attack on the pillars of feminism and scientific realities.Societies must protect their minors from decisions that, due to their state of maturity, they tend to make more impulsively and less reflexively, with greater difficulties in evaluating risks and benefits or alternatives, than those same people with greater maturity. That's why we don't let them buy cigarettes or alcohol or drive until they're eighteen. (AU)

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Introducción: Diferentes estudios señalan una gran variación en las tasas de persistencia identitaria en niños, niñas y adolescentes con incongruencia de género. Objetivo: Describir el porcentaje de persistencia y de desistencia identitaria de niñas, niños y púberes atendidos/as, por manifestación de expresiones y sentimientos de género no congruente en la Unidad de Identidad de Género (UIG). Material y Métodos: Estudio transversal en una cohorte de niñas, niños y púberes que han sido atendidos entre los años 2012 y 2020, con edades comprendidas entre 3 y los 11 años. La recogida de datos se hizo mediante la información registrada en las historias clínicas y se completó con entrevistas telefónicas a menores y progenitores que no habían sido atendidos en los últimos seis meses. Resultados: La muestra final fue de 71 sujetos, 15 (21,1%) chicos trans, 45 (63,4%) chicas trans y 11 (15,5%) no binarios/variantes de género. Vinieron 39 (54,9%) en la primera infancia (0-6 años) y 32 (45,1%) en la segunda infancia-pubertad (7-11 años). El tiempo medio de seguimiento entre la primera visita a la última fue de 2,55 años. En 65 casos (91,5%) se mantuvo persistente la incongruencia de género y en seis (8,5%) hubo desistencia. 22 (30,9%) casos habían manifestado disforia corporal, 12 (16,9%) habían comenzado tratamiento hormonal para bloquear la pubertad y de estos, la mitad, habían iniciado tratamiento hormonal cruzado. Conclusiones: La persistencia de la incongruencia de género en el grupo de infancia-pubertad es mayoritaria (91,5%). La ratio sexo-género va a favor de las niñas trans (niño a niña) y hay un incremento de sujetos no binarios/variantes de género.(AU)

Introduction: Different studies indicate a great variation in the rates of identity persistence in boys, girls and adolescents with gender incongruity. Objective: To describe the percentage of identity persistence and desistance of girls, boys and adolescents attended to, due to expressions and feelings of non-congruent gender in the Gender Identity Unit (GIU). Material and methods: Cross-sectional study in a cohort of girls, boys and pubescents who have been attended between 2012 and 2020, aged between 3 and 11 years. The data collection was done through the information recorded in the medical records and was completed with telephone interviews with minors and parents who had not received care in the last six months. Results: The final sample consisted of 71 subjects, 15 (21.1%) trans boys, 45 (63.4%) trans girls, and 11 (15.5%) gender variants. 39 (54.9%) came in early childhood (0-6 years) and 32 (45.1%) in middle childhood-puberty (7-11 years). The mean follow-up time between the first visit and the last was 2.55 years. In 65 cases (91.5%) the gender inconsistency remained persistent and in six (8.5%) there was desistance. 22 cases (30.9%) had manifested body dysphoria, 12 (16.9%) had started hormonal treatment to block puberty and of these, half had started cross-hormonal treatment. Conclusions: The persistence of gender incongruity in the childhood-puberty group is the majority (91.5%). The sex-gender ratio is in favor of trans girls and there is an increase in gender variants.(AU)

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Some people, including minors, have a gender identity that does not correspond to the sex assigned at birth. They are known as trans* people, which is an umbrella term that encompasses transgender, transsexual, and other identities not conforming to the assigned gender. Healthcare units for trans* minors require multidisciplinary working, undertaken by personnel expert in gender identity, enabling, when requested, interventions for the minor and their social-familial environment, in an individualized and flexible way during the gender affirmation path. This service model also includes hormonal treatments tailored as much as possible to the individual's needs, beyond the dichotomic goals of a traditional binary model. This guide addresses the general aspects of professional care of trans* minors and presents the current evidence-based protocol of hormonal treatments for trans* and non-binary adolescents. In addition, it details key aspects related to expected body changes and their possible side effects, as well as prior counselling about fertility preservation.

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Algunas personas, también las menores de edad, tienen una identidad de género que no se corresponde con el sexo asignado al nacer. Se les conoce como personas trans*, que es el término paraguas que engloba transgénero, transexual y otras identidades no conformes con el género asignado. Las unidades de asistencia sanitaria a menores trans* requieren un trabajo multidisciplinario, realizado por personal experto en identidad de género, que permita, cuando así lo soliciten, intervenciones para el menor y su entorno sociofamiliar, de forma individualizada y flexible durante el camino de afirmación de género. Este modelo de servicio también incluye tratamientos hormonales adaptados en la medida de lo posible a las necesidades del individuo, más allá de los objetivos dicotómicos de un modelo binario tradicional. Esta guía aborda los aspectos generales de la atención profesional de menores trans* y presenta el protocolo actual basado en evidencia de tratamientos hormonales para adolescentes trans* y no binarios. Además, detalla aspectos clave relacionados con los cambios corporales esperados y sus posibles efectos secundarios, así como el asesoramiento previo sobre preservación de la fertilidad. (AU)

Some people, including minors, have a gender identity that does not correspond to the sex assigned at birth. They are known as trans* people, which is an umbrella term that encompasses transgender, transsexual, and other identities not conforming to the assigned gender. Healthcare units for trans* minors require multidisciplinary working, undertaken by personnel expert in gender identity, enabling, when requested, interventions for the minor and their social–familial environment, in an individualized and flexible way during the gender affirmation path. This service model also includes hormonal treatments tailored as much as possible to the individual's needs, beyond the dichotomic goals of a traditional binary model. This guide addresses the general aspects of professional care of trans* minors and presents the current evidence-based protocol of hormonal treatments for trans* and non-binary adolescents. In addition, it details key aspects related to expected body changes and their possible side effects, as well as prior counselling about fertility preservation. (AU)

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INTRODUCTION: Nonsuicidal self-injury (NSSI) and suicidal behavior (SB) have a significant prevalence in transsexual people. The published data is confusing as it does not distinguish between ideation and realization, age groups, gender, or the degree of medical intervention. Their actual prevalence in Spain is unknown. OBJECTIVE: Our objective was to investigate the prevalence of NSSI behavior and SB in adolescents and young transsexual adults, differentiating between ideation and consummated behavior, prior to their receiving any type of gender-affirming medical treatment. MATERIAL AND METHODS: We retrospectively reviewed the medical history of a cohort of transsexual people aged between 10 and 35 years, treated at the Gender Identity Unit of the Valencian Community. We analyzed the data collected regarding the presence of four variables: NSSI ideation, NSSI behavior, ideas of suicide and suicide attempts, as well as differences according to age group and gender. RESULTS: The final sample consisted of 110 transsexual men and 90 transsexual women. Of these, 21% had made a suicide attempt, 50% had had suicidal ideas, 31% had a history of NSSI behavior and 35% had had NSSI ideas. No differences were found based on gender. Regarding age, subjects under 20 years of age presented a significantly higher prevalence regarding suicidal ideas compared to young adults (43% vs. 25%), while in the remaining variables, no statistically significant differences were found. CONCLUSIONS: The prevalence of a history of suicidal ideas and behavior in the Spanish adolescent and young transsexual population is significant and does not differ according to gender or age range. The prevalence of NSSI ideas and behavior differs and is more frequent in adolescent transsexuals.

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Introducción: incongruencia de género (IG) en niñas, niños y adolescentes (NNA), es un tema que se ha ido visibilizando cada vez más y es definida como una marcada discordancia entre la identidad de género y el sexo asignado al nacer. El objetivo es realizar una revisión de la evidencia en relación a la IG en NNA, las intervenciones recomendadas basadas en evidencia y finalmente dar a conocer la experiencia local en el Hospital las Higueras de Talcahuano. Métodos:se realizó una búsqueda en PUBMED artículos en inglés y español, desde 2011 a 2019. De los artículos encontrados, se revisó además la bibliografía de ellos, sumando a la revisión las publicaciones que fueran pertinentes. En la revisión práctica se realizó una sistematización de las intervenciones que se llevan a cabo a nivel endocrinológico y en salud mental. Resultados: los resultados indican que la prevalencia ha ido en aumento, al igual que la prevalencia hombre trans. Existen indicadores específicos para poder diferenciar la desistencia o persistencia de la IG. Las condiciones asociadas tales como ansiedad, depresión, ideación y conducta suicidas son generadas por el estrés de minorías y la intervención más apropiada es la afirmativa. Existe alta varianza de género en personas de condición trastorno de espectro autista (TEA), siendo mayor en las niñas que en los niños. Desde marzo 2019 Hospital las Higueras de Talcahuano inicia intervención transafirmativa con IG en NNA. Conclusiones: es necesario visibilizar el tema y despatologizarlo para que las(os) NNA tengan mayor acceso a apoyo transafirmativo.

Introduction: Gender incongruity (GI) in boys, girls, and adolescents (BGA), is becoming an ever more visible issue. It is defined as a marked misalignment between gender identity and the sex assigned at birth. Objective: to make a review of evidence regarding GI in BGA, the recommended evidence-based interventions and, ultimately, to show the local experience at Las Higueras Hospital in Tal-cahuano. Methods: A search of articles written in English and Spanish between 2011 and 2019 was performed in PUBMED and, from the articles found, their biblographies were also revised, adding the pertinent publications to the revision process. In the practical revision, a systematization of the interventions performed at an endocrinological level and in mental health, was also made. Results: the results indicate that prevalence has been increasing, as has male trans prevalence. There are specific indicators to differentiate GI desistance or persistance. The associated conditions such as anxiety, depression, suicidal ideation and conduct, are generated by the stress minorities suffer and the most appropriate intervention is the affirmative one. There is a high gender variance in people within the autism spectrum disorder (ASD), which is higher in girls than in boys. In 2019, Las Higueras Hospital in Talcahuano started with a trans-afirmative intervention with GI in BGA. Conclusions: It is necessary to make GI visible and depathologize it so that BGA have greater access to trans-affirmative support.

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INTRODUCTION: Nonsuicidal self-injury (NSSI) and suicidal behavior (SB) have a significant prevalence in transsexual people. The published data is confusing as it does not distinguish between ideation and realization, age groups, gender, or the degree of medical intervention. Their actual prevalence in Spain is unknown. OBJECTIVE: Our objective was to investigate the prevalence of NSSI behavior and SB in adolescents and young transsexual adults, differentiating between ideation and consummated behavior, prior to their receiving any type of gender-affirming medical treatment. MATERIAL AND METHODS: We retrospectively reviewed the medical history of a cohort of transsexual people aged between 10 and 35 years, treated at the Gender Identity Unit of the Valencian Community. We analyzed the data collected regarding the presence of four variables: NSSI ideation, NSSI behavior, ideas of suicide and suicide attempts, as well as differences according to age group and gender. RESULTS: The final sample consisted of 110 transsexual men and 90 transsexual women. Of these, 21% had made a suicide attempt, 50% had had suicidal ideas, 31% had a history of NSSI behavior and 35% had had NSSI ideas. No differences were found based on gender. Regarding age, subjects under 20 years of age presented a significantly higher prevalence regarding suicidal ideas compared to young adults (43% vs. 25%), while in the remaining variables, no statistically significant differences were found. CONCLUSIONS: The prevalence of a history of suicidal ideas and behavior in the Spanish adolescent and young transsexual population is significant and does not differ according to gender or age range. The prevalence of NSSI ideas and behavior differs and is more frequent in adolescent transsexuals.

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INTRODUCTION: Health care demand by transsexual people has recently increased, mostly at the expense of young and adolescents. The number of people who report a loss of or change in the former identity feeling (identity desistance) has also increased. While these are still a minority, we face more and more cases of transsexual people who ask for detransition and reversal of the changes achieved due to regret. OBJECTIVE: To report our experience with a group of transsexual people in detransition phase, and to analyze their personal experience and their associated conflicts. MATERIAL AND METHODS: A cohort of 796 people with gender incongruence attending the Identity Gender Unit of Doctor Peset University Hospital from January 2008 to December 2018 was studied. Four of the eight documented cases of detransition and/or regret are reported as the most representative. RESULTS: Causes of detransition included identity desistance, non-binary gender variants, associated psicomorbidities, and confusion between sexual identity and sexual orientation. CONCLUSION: Detransition is a growing phenomenon that implies clinical, psychological, and social issues. Inadequate evaluation and use of medicalization as the only means to improve gender dysphoria may lead to later detransition in some teenagers. Comprehensive care by a multidisciplinary and experienced team is essential. As there are no studies reporting the factors predictive of detransition, caution is recommended in cases of atypical identity courses.

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Abstract Gender incongruence is defined as a condition in which an individual self-identifies and desires to have physical characteristics and social roles that connote the opposite biological sex. Gender dysphoria is when an individual displays the anxiety and/or depression disorders that result from the incongruity between the gender identity and the biological sex. The gender affirmation process must be performed by a multidisciplinary team. The main goal of the hormone treatment is to start the development of male physical characteristics by means of testosterone administration that may be offered to transgender men who are 18 years old or over. The use of testosterone is usually well tolerated and improves the quality of life. However, there is still lack of evidence regarding the effects and risks of the long-term use of this hormone. Many different pharmacological formulations have been used in the transsexualization process. The most commonly used formulation is the intramuscular testosterone esters in a short-term release injection, followed by testosterone cypionate or testosterone enanthate. In the majority of testosterone therapy protocols, the male physical characteristics can be seen in almost all users after 6 months of therapy, and themaximum virilization effects are usually achieved after 3 to 5 years of regular use of the hormone. To minimize risks, plasmatic testosterone levels should be kept within male physiological ranges (300 to 1,000 ng/dl) during hormonal treatment. It is recommended that transgender men under androgen therapy be monitored every 3 months during the 1st year of treatment and then, every 6 to 12 months.

Resumo Incongruência de gênero é umacondição na qual o indivíduo se identifica, deseja viver e ser aceito como uma pessoa do gênero oposto ao designado por ocasião do nascimento. Na disforia de gênero o indivíduo manifesta ansiedade e sofrimento pelo desejo de viver e ser aceito como uma pessoa do gênero oposto ao designado ao nascimento. O processo transsexualizador requer trabalho em equipe multiprofissional. O objetivo do tratamento hormonal é induzir o aparecimento de características sexuais masculinas secundárias por meio da administração da testosterona em indivíduos com idade igual ou superior a 18 anos. O tratamento de estimulação androgênica costuma ser bem tolerado. Entretanto, ainda não existemevidências sobre os efeitos e riscos do uso da testosterona a longo prazo. Diferentes preparações farmacológicas da testosterona têm sido utilizadas. As mais utilizadas têm sido as injeções intramusculares de administração a curto prazo de ésteres, seguidas do cipionato de testosterona e do enantato de testosterona. Na maioria dos protocolos de tratamento observa-se o aparecimento de características corporais masculinas nos primeiros 6 meses, e a obtenção do máximo efeito da estimulação androgênica, após 3 a 5 anos de uso regular da testosterona. Recomenda-se a manutenção dos níveis plasmáticos de testosterona dentro dos limites fisiológicos para o sexo masculino (300 a 1.000 ng/dl), a fim de minimizar os riscos. A monitorização dos homens transgênero é recomendada a cada 3meses durante o primeiro ano de tratamento e a seguir, a cada 6 a 12 meses.

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