The real story on Europe’s transgender debate
Republicans are pointing to an unlikely authority in moving to ban or restrict gender-affirming care for minors: European governments.
While many U.S. medical organizations support gender-affirming care that can include puberty-blocking drugs, hormone treatments and surgery, GOP lawmakers argue progressive Europe is leading the way in limiting or barring access to care.
“Sweden, France, Norway, and the U.K. are reversing course and asking questions,” Rep. Wesley Hunt (R-Texas) said at a House Judiciary hearing this summer. “What do their doctors know that our doctors don’t?”
Numerous Republicans, including Missouri Attorney General Andrew Bailey, have also cited those countries in defending new laws banning or restricting care for minors in 21 GOP-controlled states.
But a POLITICO review of the state of care for transgender people in Europe found more nuance than Republicans critics like Hunt and Bailey often portray. While Europeans are debating who should get care and when, only Russia has banned the practice. The reassessment of standards in some European countries has aimed to tighten eligibility for gender-affirming care, but also sought to expand research studies including minors.
Whether Europeans maintain this approach, broaden access, or further restrict it will likely affect the contours of the debate in the U.S.
“There is a lot of intentional misinterpretation in the U.S. of what is happening in Europe, and that misinterpretation is happening for ideological and political reasons,” said Kellan Baker, executive director of the Whitman-Walker Institute, which focuses on LGBTQ health policy and research.
Here’s an overview of the state of transgender care in four European countries most often cited by Republican critics of gender-affirming care.
United Kingdom
Nowhere in western Europe is the debate over transgender care more heated than in the United Kingdom.
Last July, the country’s National Health Service said it would shutter the public Gender Identity Development Service at the Tavistock clinic in London, the only provider of gender-affirming care for minors in England and Wales. The NHS cited an internal review that raised concerns that children were being referred too quickly, causing an unsustainable surge in patients.
But the British haven’t banned gender-affirming care for minors and plan to open new clinics with strict eligibility criteria.
What Republicans have portrayed as a rejection of treatment for children could as easily be seen as a debate about mismanagement and clinical standards.
In announcing the Tavistock clinic’s closure, the NHS said it would “improve and expand services for children and young people experiencing gender incongruence and gender dysphoria” across the country. The promised new services would “ensure that the holistic needs” of patients are fully met, the health service said.
After a legal battle centering on care for minors, the Court of Appeal, a rung below the Supreme Court, ruled in September 2021 that doctors, not judges, should decide whether minors may consent to gender-affirming care.
For now, the NHS has delayed the closure of the clinic until March 2024, and it continues to treat existing patients, while declining new ones.
NHS plans to open two new regional clinics over the next six months.
According to the NHS, the new clinics will operate under strict guidelines. A multidisciplinary team that includes experts in pediatric medicine, autism, neurodisability and mental health will review cases.
NHS’ England branch is also considering a draft policy limiting access to puberty-suppressing hormones to minors enrolled in research studies or in exceptional cases.
France
When Republicans critical of gender-affirming care make the case for restricting or banning it for minors, they also point to France.
They have highlighted guidelines from the French National Academy of Medicine as evidence that even a country traditionally seen as among the most progressive in Europe is concerned about the growth of transgender care.
The academy warned that the risk of overdiagnosis is real and urged care in evaluating patients.
But French doctors offering transgender care said the guidelines aren’t impeding access. Children are eligible for hormone treatments with parental permission at any age and for surgical removal of breasts from age 14. However, hormones are usually prescribed around age 15 or 16 and breast surgery is usually performed after 16, said Laetitia Martinerie, a doctor in the pediatric endocrinology and diabetology department at the Robert-Debré University Hospital in Paris.
Martinerie’s department was the first in France to provide care for transgender youth 10 years ago and is the largest facility of its kind in the country.
The academy recommended that doctors get parents’ consent and use caution in prescribing those remedies, given possible side effects including weakened bones and sterility.
The guidelines also urge the involvement of a team of doctors in relevant specialties, psychological care for the patient and clear disclosure of the ramifications of irreversible surgeries.
“It has not changed anything as we were already providing multidisciplinary care,” Martinerie said.
Sweden
While Sweden was the first country in the world to allow people to legally change their gender in 1972, it has recently tightened its eligibility criteria for gender-affirming care for minors. But it hasn’t banned it.
The debate in Sweden began to heat up in 2019, when the national broadcaster SVT aired a series raising questions about transgender care for kids. Part of the coverage focused on criticism of Stockholm’s Karolinska University Hospital for allegedly rushing children into treatment and failing to adequately consider whether they suffered from mental health problems.
In May 2021, under increasing public pressure, the hospital decided that it would no longer prescribe hormones to minors and said such interventions should only be part of clinical trials.
The Karolinska hospital cited a lack of evidence about the long-term consequences of treatments and a recent influx of patients, particularly teenagers whose sex assigned at birth was female.
A year and a half after the Karolinska decision, the National Board of Health and Welfare, a Swedish government agency, updated its guidelines on gender-affirming care for minors. It stated that puberty blockers, hormones, and mastectomies should only be used in “exceptional cases,” as the risks are likely to outweigh the benefits. In addition, the board said, mental health care should be offered to patients when doctors are assessing them.
The board recommended physicians look for a long, persistent history of gender dysphoria since childhood and distress caused by the onset of puberty.
In practice, Karolinska and Sweden’s other clinics continue to have latitude to decide which cases qualify, said Edward Summanen, project manager at Sweden’s largest trans organization, Transammans.
“According to our experiences, many young trans people who need gender-affirming care can access it,” Summanem said, albeit with long wait times.
Norway
Norway made headlines last year after one of its independent agencies recommended defining gender-affirming care for minors as “experimental.” But a year-and-a-half later, those recommendations have yet to be implemented.
The guidelines proposed by the Norwegian Healthcare Investigation Board would have made it far more difficult for young trans people to receive treatment, trans organizations said at the time.
So far, the Norwegian Directorate of Health, which has the authority to set formal guidelines, hasn’t adopted the board’s recommendation.
The directorate has instead maintained current rules that allow children to receive puberty blockers once puberty has started and get hormone treatment starting at age 16. While surgical treatment is generally not applicable to minors, chest surgery can be approved in special cases.
“There is no ongoing revision to the guidelines,” Torunn Janbu, director of specialized health care services in the Norwegian Directorate of Health, told POLITICO.
