Brazilian researchers warn that healthcare for transgender people is under threat

Recent restrictions on public policies and healthcare for transgender people in several countries, including Brazil, threaten to dismantle existing care structures for this population and could lead to setbacks. This warning is contained in an article published in the scientific journal Nature Medicine by a group of Brazilian researchers.

The text discusses the new resolution (No. 2,427), issued by the Federal Council of Medicine (CFM) in April. The resolution banned the use of hormone blockers for minors under 18 in Brazil, increased the minimum age for cross-sex hormone therapy from 16 to 18, and permitted gender transition surgeries only for individuals over 21.

In addition to prohibiting the clinical use of blockers in transgender youth, the Brazilian resolution also prevents research in this area. Hormone therapy involves administering sex hormones to promote physical changes compatible with gender identity. These procedures had been adopted based on the CFM’s previous resolution (No. 2,265) published in 2020.

According to the authors, these rules not only generate an intimidating effect among health professionals but also hinder the provision of adequate care. This can increase the risk of depression, social isolation, and even suicide among transgender youth – those who do not identify with their birth sex. The group also believes that science is being stifled by limits or prohibitions on research and treatments aimed specifically at this group.

The article also calls on professional entities and the academic community – including institutions, funding agencies, scientific journals, and researchers – to reaffirm their support for evidence-based care for transgender individuals.

“Public policies and health legislation need to be based on evidence and ethical principles, not ideology. Everyone, including transgender youth and their families, health professionals, and researchers, needs to participate, be heard, and understand what’s happening,” Alexandre Saadeh, a psychiatrist and one of the authors of the article, who has been working in the field for over 35 years, told Agência FAPESP.

Saadeh is the coordinator of the Transdisciplinary Outpatient Clinic for Gender Identity and Sexual Orientation (AMTIGOS), located at the Institute of Psychiatry of the Hospital das Clínicas, the hospital complex administered by the University of São Paulo. AMTIGOS is a pioneer in welcoming transgender youth in Brazil and is recognized for its care protocols for children and adolescents. Over the past ten years, approximately 120 children and over 350 adolescents have received treatment there, out of a total of 1,300 individuals who underwent screening.

When contacted by Agência FAPESP, the CFM cited Sweden, Norway, Finland, and England, as well as the United States, as “countries that have revised their guidelines in recent years and restricted the use of puberty blockers and hormone therapy for minors, reflecting the need for more research and a more cautious approach to prescribing these drugs.”

In a statement, the council said, “The Federal Council of Medicine respects opposing opinions and reiterates that one of the objectives of the changes proposed in the resolution, based on more than 100 scientific studies published in recent years, is to protect children and adolescents from procedures that are often completely irreversible and can cause lifelong problems and sequelae.” The council added that the standard was approved in a plenary session composed of 28 federal council members from all states “of different ideological hues.”

Principle of progressive autonomy

In Saadeh’s assessment, gender identity has always existed. “It isn’t a disease, it isn’t a disorder, it’s a variation that occurs in human beings in all cultures and in all countries. We have to look at these people, listen to them, and not try to prevent them from being who they are. It isn’t by restricting rights that we’ll protect children and adolescents,” the psychiatrist argues. 

The Statute of the Child and Adolescent (ECA) ensures that young people can participate in decisions about their health through the principle of progressive autonomy.

Bruno Gualano, professor and president of the Center for Lifestyle Medicine at USP and co-author of the article, believes that the new CFM standard hinders scientific production. “The resolution removes the possibility for doctors to prescribe, for example, hormone blockers, as was done under the council’s previous standard, which had specific rules. On the other hand, it demands more scientific evidence on the effects of this procedure on young people. But if it’s prohibited, how are we going to produce evidence?” he asks.

The researchers point out that the previous CFM resolution guided the care provided to 79 transgender adolescents with puberty blockers at AMTIGOS. “Adverse effects were rare, with few discontinuing the blockers and only one expressing a desire to detransition after hormone therapy, and this occurred without regret. These results are in line with international standards, showing detransition rates below 2% when appropriate assessment protocols are followed,” the group writes in Nature Medicine.

Gualano is currently the lead researcher on the project “Eating Behaviors, Symptoms of Eating Disorders, and Obesity in Transgender Youth: A Proposal for Assessment and Intervention,” developed by nutritionist Bruna Caruso Mazzolani, who is also a co-author of the text. Supported by FAPESP, the study aims to assess behaviors and possible eating disorders and to develop and implement a specific lifestyle intervention for this population.

Preliminary data obtained by Gualano’s team suggest that AMTIGOS patients and their guardians strongly oppose the major changes introduced by the new CFM resolution. “Naturally, any proposal to change the care of transgender people should take into account what they think,” the researcher argues, hoping that the new data will shed light on the discussion.

Brazil lacks official statistics on the transgender population and has few studies and research involving these individuals, especially young people. In 2021, a survey by the Botucatu School of Medicine at São Paulo State University (FMB-UNESP), published in Scientific Reports, showed that the country has 3 million people identified as transgender or non-binary, corresponding to approximately 2% of the adult population.

The 2023 National Demographic and Health Survey (PNDS), conducted by the Brazilian Institute of Geography and Statistics (IBGE) in partnership with the Ministry of Health, included the collection of data on the sexual orientation and gender identity of Brazilians aged 18 and over for the first time. However, the results have not yet been released.

Other cases

In the United Kingdom, the National Health Service (NHS) has restricted access to puberty blockers to research settings only.

Following an Executive Order by President Donald Trump’s administration (published in January this year) prohibiting gender-affirming care for minors under the age of 19, only 14 of the 50 states decided to maintain healthcare services for transgender people in the United States. The restriction was approved despite opposition from medical bodies such as the American Academy of Pediatrics and the American Medical Association, which support care for this population based on evidence-based protocols.

The new policies have serious ethical implications for researchers, compromising everything from the right to health – “when appropriate medical care is denied for political reasons” – to the possibility of transgender people seeking care from professionals who do not recognize their gender identity.

“In Brazil, the CFM resolution may lead these young people to seek out untrained doctors or even self-medicate, jeopardizing their health. In addition, these policies have a greater impact on low-income families, threatening important achievements in rights and health,” Saadeh says.

Care at AMTIGOS

The clinic receives individuals who seek health services on their own. They fill out a registration form and then undergo screening. Upon admission, the children and young people have access to follow-up care, including psychiatric evaluations and multidisciplinary teams specializing in speech therapy, social work, psychology, psychiatry, pediatrics, nutrition, physical education, and more. Families participate in the process and guidance. The clinic serves adolescents until they reach adulthood.

“This is a moment that tests medicine’s commitment to evidence over ideology. From AIDS to reproductive rights, the scientific community has defended equity in health and integrity. (...) Medical care is necessary, ethically grounded, and widely supported by evidence. Its rollback is unjustifiable,” the researchers conclude.

About São Paulo Research Foundation (FAPESP)
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