Edited by: Dr. Josep Arimany Manso - Colegi de Metges de Barcelona, Barcelona, Spain
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Implicaciones médico-legales" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">According to the American Psychological Association, gender refers to the attitudes, feelings and behaviours that a given culture associates with a person's biological sex.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Behaviour that is compatible with cultural expectations is referred to as gender-normative; behaviours that are considered incompatible with these expectations constitute gender nonconformity.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Gender diversity, on the other hand, refers to the degree to which a person's gender identity, role or expression differs from the cultural norms prescribed for people of a particular sex. This term is becoming popular as a way of describing people without reference to a particular cultural norm, in a more affirming and potentially less stigmatising way than gender non-conformity.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The approach to gender diversity is an issue of growing interest in the public sphere, which has generated a great social debate due to its implications in the health, social, educational, legislative and professional spheres.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This article aims to update, from a medical and legal point of view, the main aspects of medical care for gender diversity.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Addressing gender diversity in childhood and adolescence</span><p id="par0020" class="elsevierStylePara elsevierViewall">The stages that have attracted most interest in addressing gender diversity are childhood and adolescence. Gender variability may be present in childhood in the form of non-normative gender expressions, without meaning that the child has a gender identity different from that assigned at birth.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The formation of gender identity is a multifactorial process that goes through self-identification, which may vary from person to person, and in which the extent to which it conforms or does not conform to that assigned at birth is evident.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Childhood and adolescence are stages of life in which people are in the midst of personality development and, therefore, sexual identity is in a phase of construction, where everything that surrounds them is changing, unstable or immature.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> They are, therefore, highly impressionable and vulnerable and, consequently, the approach to gender diversity at this age must necessarily be based on a biopsychosocial approach.</p><p id="par0030" class="elsevierStylePara elsevierViewall">From a medical point of view, concepts related to gender diversity have evolved dramatically in recent years in line with the enormous cultural change that has taken place in our society. Of great relevance are the changes introduced in the World Health Organisation's International Classification of Diseases (ICD) and the <span class="elsevierStyleItalic">Diagnostic and Statistical Manual of Mental Disorders</span> (DSM) with regard to circumstances that can be related to gender diversity. With regard to transsexual (trans) people, the ICD, in its eleventh revision (ICD-11) in 2018, removed transsexuality from the chapter on mental and behavioural disorders, moving it to the chapter on "sexual health conditions",<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> which was an endorsement of the depathologisation of trans people.</p><p id="par0035" class="elsevierStylePara elsevierViewall">On the other hand, scientific evidence suggests that gender non-conformity may be associated with increased symptoms of anxiety, depression, suicidal ideation and attempts, as well as increased risk of bullying, stereotyping and school rejection.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–10</span></a> Some studies describe a higher prevalence of different comorbidities.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11–13</span></a> In addition, the reality of each person's environment sometimes requires support from social work. Finally, it should be borne in mind that children and adolescents may have difficulties in expressing their condition, often based on the subjective views of their parents or guardians.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In this context, it is important to highlight the exponential demand for attention that gender diversity is generating. According to data from the US Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System and Youth Risk Behavior Surveillance System, in 2014 the estimated prevalence of adolescents aged 13–17 identifying as transgender was 0.7%,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> which has increased to 1.4% in the 2017–2019 survey,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> while adult prevalence has remained stable.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Since 2010, according to data from the UK’s National Health Service, a very significant increase has also been observed in adolescents, especially in girls (250 consultations with the Gender Identity Development Service in 2011–2012 vs. more than 5000 in 2021–2022).<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In our setting, the data available from the Servei TRÀNSIT de Catalunya indicate that the number of new annual cases attended to has quadrupled between 2016 and 2021; the average age of the people attended to has fallen from 34 in 2012 to 22 in 2021, with a significant increase in those under 14 years of age. There is also an accelerated change in the demographic pattern of the population served: the majority of minors are females, while the majority of adults are males.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">For all these reasons, multidisciplinary teams or units with specialised teams are necessary to allow for a comprehensive assessment, taking into account psychological, medical, social and ethical aspects, in accordance with the needs of each person and family,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> which, in turn, guarantees the quality of care and clinical safety, as well as action based on appropriate ethical and deontological principles. Any health intervention must follow the principles of scientific rigour, accumulated experience, ethical and deontological principles and the necessary caution in the face of chronic treatments that are not free of complications and, in some cases, may prove irreversible.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> It is essential that the team caring for these people and their families have a respectful, inclusive and prudent attitude.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Professionals must provide clear and easy-to-understand information for the minor and their parents or guardians about the procedures (including potential risks and benefits, expectations and limitations, and the possibility of reversibility of the options), as well as the need for psychological and endocrinological evaluations, assessing the existence of comorbidities, whether or not associated with the trans condition, and prioritise tools that promote a psychological approach over a pharmacological one.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">It is important to note that detransition processes are not exceptional, especially in adolescents. According to a study conducted in the USA by Olson et al.,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> 7.3% of minors detransition during the 5 years following social transition. Therefore, it is important to be cautiously accompanied by expert professionals, avoiding rushing into medicalised interventions, such as hormone treatments, which can lead to permanent sequelae. The scientific evidence on the use of these treatments is scarce and even more so on their prolonged use.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23,24</span></a> In this sense, it is important to consider the experiences of other countries, such as Finland or the United Kingdom, which have reversed more invasive models of care for self-identified trans minors to more evaluative models of care, limiting the indiscriminate use of hormone treatments and prioritising psychological care and support,<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21,25–28</span></a> which compels us to be cautious.</p><p id="par0065" class="elsevierStylePara elsevierViewall">All this highlights the need for an extensive, careful, detailed and comprehensive informed consent process, informing of the scientific evidence of the treatments, that their use is off-label, as well as the potential expected benefits and possible short and long-term side effects. The participation of minors in the decision-making process should be encouraged in accordance with their degree of maturity.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This is set out in Law 4/2023,<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> for the real and effective equality of trans persons and for the guarantee of the rights of LGTBI persons, stating that the granting of prior informed consent shall be carried out in accordance with the provisions of Law 41/2002, of 14 November, basic law regulating patient autonomy and rights and obligations in the field of information and clinical documentation.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In summary, gender diversity requires a biopsychosocial approach, taking into account the existing scientific evidence, working in multidisciplinary and specialised teams and placing special emphasis on the appropriate medical information process.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Legal aspects</span><p id="par0075" class="elsevierStylePara elsevierViewall">On the other hand, from a legal perspective, the recent publication of various legal regulations dealing with these aspects (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) and the changes they entail have triggered an intense debate in society as a whole and also among medical professionals.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3,31</span></a> The most recent of these, Law 4/2023, concerning the real and effective equality of trans people and the guarantee of the rights of LGTBI people<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> has once again come to modify the possible intervention of professionals in such situations, whether in healthcare or at a judicial level. According to its preamble, the aim of this law is to develop and guarantee the rights of lesbian, gay, bisexual, trans and intersex people, eliminating situations of discrimination in order to ensure that sexual orientation, sexual identity, gender expression, sexual characteristics and family diversity can be lived in full freedom in Spain.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Section 3, Measures in the field of health to promote the real and effective equality of trans people, in Chapter II of Law 4/2023, on Public Policies, states, in Article 56, on Comprehensive health care for trans people, that such health care shall be carried out in accordance with the principles of non-pathologisation, autonomy, informed decision and consent, non-discrimination, comprehensive care, quality, specialisation, proximity and non-segregation. In all cases, respect for their privacy and confidentiality regarding their physical characteristics must be ensured, avoiding unnecessary examinations or their exposure without a directly related diagnostic or therapeutic objective.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Likewise, Article 58, on Training of health personnel, research and monitoring, states that public administrations, within the scope of their competences, shall guarantee sufficient, continuous and updated training for health personnel, which takes into account the specific needs of transgender people, paying special attention to the health problems associated with the surgical procedures they undergo, hormone treatments and their sexual and reproductive health, promote research in the field of health sciences, as well as technological innovation, in relation to health care for trans people, establish indicators that enable monitoring of treatments, therapies and interventions for trans people, as well as procedures for assessing the quality of care throughout the entire care process.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Finally, Article 59, on health protocols and specialised services, establishes that public administrations, within the limits of their competence, shall draw up and develop specific protocols and procedures for the care of trans people, and may create specialised services made up of multidisciplinary teams of professionals who, among other things, shall inform, support and accompany trans people throughout the transition process, provide support for outpatient care and specialised territorial centres, and conduct research, statistics and monitoring of the system as a whole. Finally, the law stipulates that the Ministry of Health, through the Spanish Agency for Medicines and Medical Devices, will ensure sufficient supply of the medicines most commonly used in hormone treatments for trans people and will supervise their supply, in order to avoid recurrent shortages.</p><p id="par0095" class="elsevierStylePara elsevierViewall">On the other hand, Title II of Law 4/2023 contains a series of measures to promote real and effective equality for trans people. Chapter I regulates the correction of the gender of a person in the registry and the adequacy of the documentation, the recognition of the freely expressed will, the depathologisation of the procedure and the elimination of the legal age for requesting the correction (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Thus, in accordance with the legitimacy established in Law 4/2023 for the correction of the person’s sex registered at birth (see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), the professional forensic intervention, dispensed by the Institutes of Legal Medicine and Forensic Sciences, both medical and psychological, will only be compulsory in the case of persons under 14 years of age and over 12 who, in accordance with Law 15/2015, of 2 July, of the Voluntary Jurisdiction, submit their request for the correction of the person’s sex registered at birth before the competent Court of First Instance.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In these cases, the least intervention possible should be encouraged, with the aim of conducting a joint assessment, whenever possible, in the presence of the judicial authority, the forensic doctor and the forensic psychologist. The forensic assessment in these cases, always in consultation with the minor's legal representatives, is not easy due to the lack of specific tests validated in Spain for this assessment, which guarantee an objective and scientifically rigorous evaluation. In order to avoid decisions based on impulsivity or motivated by peer pressure or social networks, among others, it is important to assess the permanence and continuity of the motivation for the request, with adequate support and follow-up.</p><p id="par0110" class="elsevierStylePara elsevierViewall">In short, medical care for gender diversity is governed by different regulations with different hierarchies. The recent Law 4/2023 for the Real and Effective Equality of Trans People and for the Guarantee of the Rights of LGTBI People has modified the possible medical and legal intervention of professionals in such situations.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="par0115" class="elsevierStylePara elsevierViewall">The formation of gender identity in childhood and adolescence is a multifactorial process that varies from person to person. Care for minors with gender dysphoria should be based on a biopsychosocial approach, individualising each case, with careful assessment and always with the best interests of the minor in mind.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The use of up-to-date clinical practice guidelines, developed by experts using a multidisciplinary approach, is essential.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Health professionals must be guarantors of the minor's wellbeing, always seeking his or her best interests, being judicious and not acting hastily in prescribing treatments that may have irreversible consequences, if not fully justified.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflict of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">There are no conflicts of interest.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">There have been no external sources of funding.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Informed consent</span><p id="par0140" class="elsevierStylePara elsevierViewall">The submitted manuscript does not contain patient data and therefore informed consent is not required.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Addressing gender diversity in childhood and adolescence" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Legal aspects" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Informed consent" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-11-28" "fechaAceptado" => "2024-01-28" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Monograph on Legal Medicine, Professional Liability and Clinical Safety.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">International (Human Rights Council of the United Nations)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Resolution adopted on 17 June 2011 (A/HRC/RES/17/19) "Human rights, sexual orientation and gender identity".</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Resolution adopted on 26 September 2014 (A/HRC/RES/27/32) "Human rights, sexual orientation and gender identity".</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Resolution adopted on 30 June 2016 (A/HRC/RES/32/2) "Protection against violence and discrimination based on sexual orientation and gender identity".</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Report A/HRC/29/23 of 4 May 2015 of the United Nations High Commissioner for Human Rights and reports of the Office of the High Commissioner and the Secretary-General on "Discrimination and violence against persons on the basis of sexual orientation and gender identity".</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">European Union</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Treaty on European Union (Articles 2 and 3) on non-discrimination as one of the core Community values</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Treaty on the Functioning of the European Union (Article 19) on the empowerment of the Council to take appropriate action to combat discrimination based on sex, racial or ethnic origin, religion or belief, disability, age or sexual orientation</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Charter of Fundamental Rights of the European Union (Article 21) on the prohibition of discrimination on the grounds of sexual orientation</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">European Court of Human Rights, noting the prohibition of discrimination under Article 14 of the European Convention on Human Rights, including issues related to gender identity, and urging that a change of registered sex be guaranteed without the prerequisite of undergoing medical procedures such as sex reassignment surgery or hormone therapy</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Spain</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Spanish constitution</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Article 14 on the right to equal treatment and non-discrimination on the grounds of birth, race, sex, religion, opinion or any other personal or social status or circumstance \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Article 10: on the dignity of the person and the free development of the personality as foundations of political order and social peace \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Article 9.2, on the obligation of the public authorities to promote the conditions for the real and effective freedom and equality of the individual and of the groups to which he/she belongs, and also to remove obstacles that prevent or hinder their full enjoyment. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Article 10(1), on the principle of free development of personality, which affects the right to change the registration of gender and is also a projection of the fundamental right to personal privacy enshrined in Article 18(1) of the Constitution. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Constitutional Court</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>According to the Constitutional Court's decision 99/2019, "this enables the individual to make legally effective decisions about his or her identity. Self-identity, which includes aspects such as name and gender, is a fundamental quality of the individual. Establishing one's own identity is not just another act of the person, but a vital decision, in the sense that it places the subject in a position to be able to develop his or her own personality". This ruling declares unconstitutional Article 1.1 of Law 3/2007, of 15 March, which provides for the correction of the person’s sex registered at birth, in so far as it does not include minors with "sufficient maturity" and who are in a "stable situation of transsexuality" among those entitled to legal status". \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Supreme Court</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Supreme Court decision 685/2019, of 17 December 2019, in line with STC 99/2019, of 18 July 2019. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Law 3/2007, of 15 March, which regulates the correction of the sex registered at birth, recognised the possibility for trans persons of legal age and Spanish nationality to change their sex registration without having to undergo a sex reassignment operation and without prior judicial proceedings, although the need for a diagnosis of gender dysphoria remains. Through this same law, Law 14/2006, of 26 May, on assisted human reproduction techniques, was modified, recognising, for the first time, dual motherhood within female marriages. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Law 4/2023, for the real and effective equality of trans people and for the guarantee of the rights of LGTBI people. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3541872.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Legislation relevant to gender diversity.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Legitimacy or who can request a correction of the sex registered at birth (Article 43)?</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>As a general rule, any person of Spanish nationality over 16 years of age may apply to the Civil Registry Office to correct the registration entry concerning gender \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Persons with disabilities may request, with any necessary support measures, the correction of the sex registered at birth \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Persons under 16 years of age and persons over 14 years of age may submit the application themselves, assisted in the proceedings by their legal representatives. In the event of disagreement between the parents or legal representatives or between the parents or legal representatives and the minor, a legal guardian shall be appointed in accordance with the provisions of the Civil Code. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Persons under 14  and over 12  years of age may request judicial authorisation for the amendment of the registration of sex under the terms of Chapter I bis of Title II of Law 15/2015, of 2 July, on Voluntary Jurisdiction, whereby the Court of First Instance of the domicile of the person whose registration is to be rectified or, if not in national territory, that of their residence in said territory, shall be competent to hear this case. The proceedings must be brought with the assistance of his legal representatives. In the event of disagreement between the parents or legal representatives, between themselves or with the minor, a legal guardian shall be appointed in accordance with the provisions of the Civil Code. The intervention of a lawyer or solicitor shall not be compulsory in the processing of the case. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Competent authority (Article 45)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">The person in charge of the Civil Registry Office where the application was lodged shall be responsible for processing the gender correction procedure of the applicant.</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Reversibility (Article 47)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>After 6 months have elapsed since the entry in the Civil Register of the correction of the sex registered at birth, the persons who have requested such correction may restore the registration entry relating to gender that appeared in the Civil Register prior to the correction, following the same procedure established in this Chapter for the correction of the registration entry. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>If a new correction is required after the first correction has been made, the procedure established in Chapter I of Title II of Law 15/2015 of 2 July 2015 on Voluntary Jurisdiction must be followed. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3541873.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Main characteristics regarding the correction of the sex registered at birth, in accordance with Law 4/2023, for the real and effective equality of trans people and the guarantee of the rights of LGTBI people (articles 43, 45 and 47).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:31 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "American Psychological Association. Key terms and concepts in understanding gender diversity and sexual orientation among students. Informational Guide. [Accessed 20 February 2024]. Available from: <a target="_blank" href="http://www.apa.org/pi/lgbt/programs/safe-supportive/lgbt/key-terms.pdf">www.apa.org/pi/lgbt/programs/safe-supportive/lgbt/key-terms.pdf</a>." ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Documento de posición del Consell de Col·legis de Metges de Catalunya. La atención a la diversidad de género en personas menores de edad. Enero de 2023. [Accessed 20 February 2024]. 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