Why European Countries Are Rethinking Gender-Affirming Care for Minors | Best Countries

Chase, a transgender teenager who identifies as non-binary, has been trying to access gender-affirming health care in the United Kingdom since they were 13 years old. Now 16, they’re still waiting.

Chase – who lives just outside Manchester with their parents – has been officially on a waitlist for care within the National Health Service system for more than a year due to high demand and, more recently, operational delays. They say the long wait has been harmful to their mental health and, about six months ago, they decided to turn to private hormone therapy treatment.

Due to an ongoing independent review of gender identity services for youth in the U.K. commissioned by its public health authority, minors like Chase might be waiting a while for clarity. Theresa, Chase’s mother, notes that because of the uncertainty around possible care-related policy changes, their situation can feel like “death by a thousand cuts.” (The names of Chase and Theresa have been changed to protect their privacy.)

“It’s infuriating really,” Chase adds.

The U.K. is not the only European country that is rethinking how to approach gender-affirming care for minors. Several countries, including traditionally more progressive nations like Sweden and Norway, are changing guidelines at least in part due to questions from some doctors about the risks of such procedures. The changes in Europe are occurring more often at the health care policy level initiated by medical professionals, rather than through new or adjusted laws pushed by legislators, and experts say they haven’t been politicized to the extent they have been in the U.S.

“This is not a legal battle in Europe,” says Cianán Russell, a senior policy officer at ILGA-Europe, the European arm of the International Lesbian, Gay, Bisexual, Trans and Intersex Association. Rather, “governments are changing guidelines or instructions to different institutions, or the institutions are changing their policies themselves.”

The Human Rights Campaign, an LGBTQ+ advocacy group based in the U.S., defines gender-affirming care as “age-appropriate care that is medically necessary for the well-being of many transgender and non-binary people who experience symptoms of gender dysphoria, or distress that results from having one’s gender identity not match their sex assigned at birth.” Care can come in a variety of ways, from mental health support to hormone treatment like what Chase is using, to, in some cases, surgical procedures. Advocates say holistic support, or a combination of mental and medical treatments – which is recommended in the World Professional Association for Transgender Health’s standards of care – is generally the best approach.

In the U.S., conservatives often oppose the concept of youth gender-affirming due to religious beliefs and concerns about child abuse. However, in Europe the reluctance appears to be more based on science than politics, with some medical professionals questioning the health risks of administering transitional treatments on minors. One 2022 report commissioned by the Swedish government, for example, concluded that the “scientific basis is not sufficient” to continue to conduct hormone treatments on children without further research.

“Health care should not provide interventions that we do not know to be safe and beneficial,” Mikael Landén, a professor and chief physician at the University of Gothenburg in Sweden and co-author of the report, wrote in an email. “From the lack of evidence follows that a conservative approach is warranted.”

But the broader picture in Europe is not all negative from the perspective of those in favor of trans rights, Russell says, and there are plenty of examples of trends viewed positively by advocates. They say that more than 60% of the total population of the European Union – including countries such as Belgium, Germany, Italy and the Netherlands – have “clear policies in place about offering transition-related care to minors,” such as puberty blockers and hormone treatments. Additionally, the recently updated trans rights map published by Transgender Europe – a nonprofit that promotes the full equality and inclusion of all trans people on the continent – finds that 25 of the 27 E.U. member states provide legal gender recognition procedures.

A more detailed picture given by the organization brings some cause for worry, however. Of the 25 E.U. members that offer those procedures, four demand sterilization, only one offers full non-binary recognition and less than half (12) offer legal gender recognition procedures for minors.

In recent years, at least a handful of European countries have gently tapped the breaks on gender-affirming care for minors.

In Finland, specialized adolescent psychiatric gender identity teams have been available for minors at two university hospitals since 2011 through the country’s adoption of the so-called “Dutch approach,” which in part holds that adolescents experiencing gender dysphoria “can be considered eligible for puberty suppression and subsequent cross-sex hormones when they reach the age of 16.” But after years of additional research, a public health body in Finland recommended that minors experiencing gender dysphoria first be provided with psychological support and, if further medical treatment is pursued, that the patient be made “aware of the risks associated with them.”

In 2022, the Swedish government’s National Board of Health and Welfare said hormone treatments for minors “should be provided within a research context” and offered “only in exceptional cases,” while adding that the “risks of puberty suppressing treatment … and gender-affirming hormonal treatment currently outweigh the possible benefits.”

In Norway, the country’s Healthcare Investigation Board recommended in part that gender-affirming care treatments such as puberty blockers be defined as experimental. Meanwhile in France, the Académie Nationale de Médecine in February 2022 recommended the “greatest reserve” when considering puberty blockers or hormone treatments due to possible side effects such as “impact on growth, bone weakening, risk of infertility” and others, according to a translation.

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Marci Bowers, the president of the World Professional Association for Transgender Health, says the situation around youth gender-affirming care in some European countries is indeed different than in America – but she has confidence in the direction that ongoing research is headed.

“(European countries) are trying to be objective,” Bowers says. “Although they are forcing patients to become research subjects, basically, as a condition of their care, the good news is that they fund that research.”

Questions about treatment will be answered, she adds, and “they’re probably going to be answered affirmatively.”

Russell, of ILGA-Europe, believes the questions around health care for transgender youth on the continent are coming from a “small minority,” but that the “vast majority of doctors who work with trans people day-in and day-out support the kind of care” promoted by the World Professional Association of Transgender Health’s standards of care. They also reference the World Health Organization’s latest International Classification of Diseases, which describes gender incongruence as a sexual – not mental – health condition.

If there is a consensus, it hasn’t been reflected in Chase’s experience.

In late 2022, Reuters reported that England’s National Health Service – as part of its review of gender-affirming care for minors – was considering calling for local authorities to be alerted about cases in which families pursue private care for their transgender children outside of the public system. Chase’s family was one of those that had pursued private options, though they were unaware of the potential consequences.

Chase and their mom Theresa visit Whitby Abbey in England. (Courtesy of Lily)

Theresa says they were referred to social services, but that the case was eventually resolved when Chase’s general practitioner assured a representative that Chase was “competent to make their own decisions about their health care” and not being pressured to access private testosterone treatment by their parents.

Almost two years after the review was launched, the NHS last summer announced that it would be decommissioning the Gender Identity Development Service, or GIDS – England’s only clinic geared toward youth with gender dysphoria – and transitioning its services to two regional hubs. The latter piece of the news was largely applauded by advocates. The changes came after the independent review commissioned by the NHS found, in part, a “lack of clinical consensus and polarized opinion on what the best model of care for children and young people experiencing gender incongruence and dysphoria should be” in the country.

But activists have still expressed concern over GIDS’ already long waitlist coupled with delayed openings for the regional locations, along with the fact that no new appointments will be scheduled until one hub opens in late 2023. Bowers notes the difficulty for these children that can come with waiting, adding that the effects of puberty can be “pretty depressing” for some with the angst they are already experiencing.

In the meantime, leaked draft guidelines make the situation even more cloudy. The NHS recently announced an interim policy holding that “puberty-suppressing hormones should not be routinely commissioned for children and adolescents” outside of research settings, citing the “significant uncertainties” surrounding the use of hormone treatments.

The ongoing review’s final report – and, thus, official guidance for how youth gender-affirming care should move forward – is set to be released later this year.

“I talk to young people all the time,” says Kai O’Doherty, the head of policy and research at Mermaids, a nonprofit organization based in the U.K. that supports trans youth. “It seems like they’re completely absent from, actually, the conversation of what they need and what they’re gonna get.”

Deekshitha Ganesan, a policy officer focused on health at Transgender Europe, says something that’s often forgotten in the recent debate about access to gender-affirming health care is that trans people’s quality of life and, as a result, ability to participate in society, “has improved so greatly” by having that access to such care.

For now, however, transgender minors across several European countries will continue to face uncertainty.

“I’m lucky in that I have a really good support system and stuff like that, but occasionally I think, ‘Things are getting worse. I’m getting older,’” Chase says. “Honestly, the thing I think is best for me at the minute is to go somewhere else. Like I honestly don’t know what would happen if I stayed here, you know what I mean? But then it’s like, where would you go? Because it’s the same in America. It’s the same in a whole lot of places.”

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