Providing care to transgender people is a complex task, and treatment options should be tailored to each individual. Preliminary research suggests that gender affirmation can improve the mental health and quality of life of transgender people, both directly (through the effect of affirmation on well-being) and indirectly (through reduced exposure to minority stressors such as discrimination and violence). There are multiple domains of gender affirmation for transgender people: social (changing name and pronouns), legal (changing gender on official documents), medical (including hormonal therapy) and/or surgical affirmation (including mastectomy, vaginoplasty, orchidectomy and so on).

The access to the different domains of gender affirmation differs widely among countries, leading to huge inequalities (table 1).1 Just a few miles can dramatically change the present (as they might not have access to specific or appropriate care during childhood and adolescence) and the future (lacking the perspective of a fulfilled life in adulthood) of young people with gender dysphoria. In Europe, for instance, there are ‘multiple speeds’ in transgender rights: while some nations are pushing forward (legal gender change, optional surgical intervention, hormonal treatment before the age of 18), others are going back (questioning or revoking the right to access gender-affirmation procedures). Young transgender people continue to face disparities in access to care, both as availability of specialised paediatric services (eg, in England, there is a single English service, based in London and Leeds, while in Spain, there are more than ten centres for a smaller population) and as the quality of psychological and medical care (with ‘non-official pseudo-units’ …