Portugal: What to Expect from the Political Environment Regarding Gender Medicine

By Marisa Antunes

Photo by Pasqualino Capobianco from Unsplash

Twenty-twenty-four will be remembered as the year the fortress of gender ideology began to crumble. The WPATH Files scandal hit in March, followed by the Cass Report a month later. Then. in June, an article in the New York Times exposed that the Biden administration pressured the WPATH (World Professional Association of Transgender Health) to remove the age limits for trans youth surgeries in their Standards of Care (SOC 8). These revelations made public what many already knew or suspected and brought hope to the families of young people trapped in this painful identity spiral. 

This autumn, the epicenter of gender medicine will shift to Lisbon, Portugal. On the one hand there is the WPATH 28th Scientific Symposium “A Gender Diverse World in Global Unity”, where some of the most well-known practitioners in the field of gender medicine will gather. On the other is the Genspect Bigger Picture Conference, 'Reframing the Future' where trans-critical scientists, medical practitioners, researchers, and others from across disciplines will gather to challenge to the evidence base for gender medicine and address the damage that trans ideology has wrought. But what is that atmosphere around gender like for ordinary Portuguese?  

Thanks to 8 years of carefully planned policy initiatives by the former socialist government under former Prime Minister António Costa, (recently elected President of the European Council) the progressive wave is riding high. Portugal approved the law on the self-determination of gender identity in 2018 and the law on conversion therapies ban in 2023. LGBT associations have become extremely influential, and many schools have already implemented trans-friendly rules on pronouns and social transition. The College of Psychologists actively promotes the theory of social construction, and a transwoman won the Miss Portugal beauty contest. Finally, most of the media are ideologically captured. Articles involving gender medicine often only quote trans activists, seldom giving a voice to actual health professionals. 

The “trans train” arrived in Portugal late and only escalated following the pandemic. For instance, an average of 10 people per week change their name and gender (including at least one minor) and the Serviço Nacional de Saúde (the public health system, like the NHS) currently carries out an average of two sex reassignment surgeries per week. 

The leader of health strategy for the LGBTI community in the new right-wing government (AD, elected this year) is sexologist Zélia Figueired, who also performed the same functions in the socialist government, and was reappointed to the position in April this year. 

In the months before the WPATH leaks, I had the opportunity to interview Dra Zélia Figueiredo, for an article published last January in Sábado, one of the country's main news magazines. As part of the assignment, I spoke with a group of doctors from health centers - the first medical line for young people questioning their identity - regarding their concerns about official guidelines on transgender health issues. They told me that the document “From transsexuality to gender dysphoria: approach protocol and guidance in primary health care”, part of the training required for doctors, continues to recommend puberty blockers for children as a “reversible” therapeutic option”, ignoring follow-up studies that led countries like Finland, Sweden, Norway or France to restrict the use of puberty blockers, even before the Cass review. 

According to these guidelines, doctors must follow a therapeutic approach aligned with WPATH’s Standards of Care (currently involved in controversy). Young people experiencing ROGD (Rapid Onset Gender Dysphoria) must be evaluated according to the "logic” of gender self-determination: self-diagnosis, followed by immediate validation by the clinician. In Portugal, a clinician who questions the cause of dysphoria can be accused of conversion therapy which carries a prison sentence of up to three years.   

When I interviewed Dra Zélia Figueiredo, a staunch supporter of the so-called affirmative approach recommended by WPATH, she confirmed the exponential rise in the number of cases involving trans-identified young people not only in public hospitals but also in private clinics. She even shared the statistical data on her own private appointments, which have doubled since the pandemic so that she now receives an average of nine new patients per month. 

She confirmed that the profile of these patients has changed a lot in recent years, “The majority are trans boys (they were born girls and want to change into boys) but, since the pandemic, the number of trans girls (boys changing into girls) has also increased….” 

The age profile is also changing. Going back five or more years, the people coming to gender consultations were adults, but she said, “Now they are getting younger and younger” Zélia Figueiredo confirmed. She attributed this exponential increase to “the access to more information” and vehemently ruling out the hypothesis that it could be a fad or social contagion. “Teenagers today are very well informed,” she assured me, “these people know very well who they are, they have already talked to their families and many even come to their parents, who also know perfectly well what it is about." 

In a recorded interview, the doctor emphasised that comorbidities such as depression or an autism spectrum diagnosis, for instance, are no longer a reason for not making the transition. So, are there ever instances when she will not validate a self-diagnosis? “To someone who has a psychotic condition,” she answered. 

The waiting time before a young person can be put into hormone therapy in the public Portuguese hospitals, varies. I interviewed some parents whose daughters were recommended testosterone in just one appointment. 

According to Dr Zélia Figueiredo, the time between the first appointment with the psychiatrist and the endocrinologist when hormone therapy begins, it is supposed to take, on average, a period of six months spread over four consultations. But even if those four appointments occur, several psychologists who spoke to me without the benefit of anonymity, told me, that these appointments last just over 15 or 20 minutes, no more. 

Many young people who start hormone therapy move on to have surgery. Given the irreversible nature of such treatments and the inexperience and immaturity of young patients, I asked Dr Zélia if four, brief medical appointments would be enough time to determine a diagnosis. Would there be time to uncover comorbidities such as depression, autism spectrum, sexual trauma? She told me, “They are all already depressed. The WPATH SOC concludes that young people always test as “depressed” and or anxious in personality tests, so we stopped asking for these tests because it does not invalidate the transition.” 

Since the article, published in January ‘24, the release of the WPATH Files and the Cass Report have sent waves through waves through gender consensus in several countries, such as Belgium and Netherlands, just to name a few. So, what about Portugal? I contacted the Ministry of Health to try to understand the situation in Portugal in terms of gender medicine in the wake of these events knowing Zelia Figueiredo’s support for the WPATH Standards of Care. 

This time, I had no chance to interview Dra Zélia in person or by zoom. The questions had to be sent by email. So, I emailed the following question: “Dra Zélia Figueiredo is an avowed defender and follower of the "Standards of Care" of the World Professional Association for Transgender Health (WPATH). WPATH and the affirmative approach it advocates, have been involved in a series of controversies that discredit the organization. Has the WPATH leaks scandal changed the guidelines of the "affirmative approach" that was implemented in the public health service by Dra. Zélia, before the change of Government? 

The answer from the Ministry of Health office, is as follows: “The Health Strategy guideline for Lesbian, Gay, Bisexual, Trans, and Intersex People remains unchanged. This is based on scientific evidence, advocating a person-centered approach and in accordance with free and informed consent. Any health intervention must be based on Legis artis, ethical and deontological principles and simultaneously guarantee the quality and safety of the care provided.” 

I also asked: “What impact has the Cass Report and the discussion around holistic approach in gender medicine had on the message/training that have been passed to Portuguese healthcare professionals?.” The answer: “The main message to be passed to healthcare professionals is that care provision must remain person-centered, through a systemic approach, in accordance with scientific evidence and the best interests of the child/young person. Therefore, it is important to include the health history of the child/young person and their stage of development (including cognitive, emotional, and social maturity). The complexity and need to modulate health care appropriate to the health condition of each child/adolescent and their family or significant others and their psychosexual development are accepted, which implies individualized clinical decisions with the multidisciplinary health team.” 

The Ministry of Health office also sent me the number of trans surgeries between January and May this year: 45 surgeries during five months, more than two per week. Unsurprisingly, the profile shows an unequal number between sexes – 87% of surgeries were performed on girls who are transitioning to boys. 

In this spiral of numbers, as these young people are losing healthy parts of their bodies, it is urgent to understand who is experiencing a phenomenon of social contagion and who is suffering from real gender dysphoria. In both cases, psychotherapy is urgent. It is inevitably a controversial topic, and it will take time to reach consensus but one whose sensitivity makes greater reflection and debate inescapable because the stakes are so high for children and young people with identity crises. 

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