Increasing Number Of European Nations Adopt A More Cautious Approach To Gender-Affirming Care Among Minors

Increasingly, European nations are adopting a more cautious approach to gender-affirming care among minors. In March of this year, for example, the Norwegian Healthcare Investigation Board announced it would revise its current clinical recommendations with respect to “gender-affirming care” for minors. The updated guidelines would restrict the use of puberty blockers, cross-sex hormones, and transition-related surgery to clinical research settings. Norway joins other European nations, such as Finland, Sweden, and the U.K., in introducing limits on the provision of gender-affirming care to minors.

In the U.S, a partisan divide is shaping up between states that allow for and guarantee access to youth gender-affirming care, and states that ban or severely restrict gender-affirming care for minors. There doesn’t appear to be much middle ground.

Thus far this year, 12 states have either banned or severely limited gender-affirming care for minors. It’s expected that more Republican-led states will soon follow suit.

At the same time, five Democrat-led states have passed legislation designed to legally protect transgender healthcare coverage and access for minors.

As seen by proponents and advocates, the idea behind gender-affirming care is to offer medical treatment so that a person can “live as the gender they are.”

There is some evidence that in the short-term gender-affirming care yields improvement in health outcomes, in terms of less depression, anxiety, and suicidality.

Angela Goepferd, program director for gender health at Children’s Minnesota says that access to healthcare for trans minors is “lifesaving.” Goepferd suggests that children with access to gender-affirming care “have less anxiety, less depression, they think about suicide less often and they act upon those suicidal thoughts less often.”

In the U.S., talk of introducing guardrails is sometimes met with being branded “transphobic” or a “science denier.”

But caution with respect to gender-affirming care for minors may be warranted, as European experience indicates. A series of Europe-based systematic reviews of evidence for the benefits and risks of puberty blockers and cross-sex hormones have shown a low certainty of benefits. Specifically, longitudinal data collected and analyzed by public health authorities in Finland, Sweden, the Netherlands, and England have concluded that the risk-benefit ratio of youth gender transition ranges from unknown to unfavorable.

As a result, across Europe there has been a gradual shift from care which prioritizes access to pharmaceutical and surgical interventions, to a less medicalized and more conservative approach that addresses possible psychiatric co-morbidities and explores the developmental etiology of trans identity.

In turn, this has brought about the imposition of restrictions in Europe on access to hormones. Currently, minors in most European countries can access puberty blockers and cross-sex hormones, but only if they meet stringent eligibility conditions. And, this is increasingly done in the context of a tightly controlled research setting.

Many European countries do not allow the use of cross-sex hormones until age 16, and only then after completing a number of psychotherapy sessions. In addition, the vast majority of European countries ban surgery until age 16.

From puberty blockers to cross-sex hormones to surgery, the rules across Europe tend to be either stricter than many jurisdictions in the U.S. or in the process of tightening. For example, Sweden’s National Board of Health and Welfare states children should not receive puberty blockers outside clinical trials, and they must be at least 12.

In England, among the reasons for shutting down Tavistock’s Gender and Identity Development Service in 2022, physicians reported concerns that some patients were referred to a gender transitioning pathway too quickly. Hilary Cass, who led an independent review of gender identity services for children and young people, said there was “insufficient evidence” for her to give any firm advice regarding the routine use of puberty blockers. She has told the National Health Service to “enroll young people being considered for hormone treatment into a formal research protocol.”

In Finland, gender experts have expressed concern that some patients who’ve been prescribed drug treatments didn’t meet the strict eligibility requirements detailed in the so-called Dutch Protocol. In the 1990s, Dutch gender specialists began laying the foundation for gender-affirming healthcare for minors. Described as a “careful and cautious approach” it was devised by clinicians and documented meticulously, from the late 1990s, through 2012.

As it was envisioned, the Dutch Protocol laid out a set of criteria for treatment eligibility. There needs to be a documented early childhood onset of gender dysphoria, increase of gender dysphoria after pubertal changes, absence of significant psychiatric comorbidity, and demonstrated knowledge and understanding of the consequences of medical transition. Treatment with puberty blockers can only be initiated starting at the age of 12. Interventions with clearly irreversible effects, which include cross-sex hormones and surgery, are not available until ages 16 and 18, respectively. Should patients go through with the transitioning process, all youth are provided with psychotherapy throughout.

Finland was among the first countries to adopt the Dutch Protocol for pediatric gender medicine. By 2015, however, Finnish gender specialists were noticing that most of their patients did not meet the Dutch Protocol’s relatively strict eligibility requirements for drug treatments.

Clinicians in other European countries also observed that guidelines were not being strictly followed, effectively allowing for what could be deemed as unauthorized treatment of many more minors – especially girls – than was envisaged by the Dutch experts who devised the original protocol.

Ultimately, this gave rise to health authorities in Finland, Sweden, and the U.K. conducting systematic reviews of evidence for the benefits and risks of hormonal interventions. Subsequently, the findings from these reviews suggested that studies cited in support of hormonal interventions for adolescents are of “very low” certainty. In turn, this led to the placement of severe restrictions on access to hormones. It also advanced the notion that such interventions are still in an “experimental” phase.

De facto, according to European health authorities and medical experts, there isn’t yet a medical consensus for the use of pharmaceutical and surgical interventions in gender dysphoric minors.

In an article published in February of this year in the Netherlands, the author concludes that “more research on sex changes in young people under the age of 18 is urgently needed,” in particular, referring to the importance of examining the long-term effects of medicalized transgender care.

What is remarkable about the article is that it quotes extensively from one of the original members of the Dutch team of researcher-clinicians who pioneered the use of puberty blockers in children with gender dysphoria more than two decades ago.

To be sure, the Dutch have generally been more careful – even than their European colleagues – in the use of interventions such as puberty blockers. Many Dutch physicians practice “watchful waiting” prior to moving forward with treatments.

Furthermore, recent data analyzed by Dutch clinicians has given them pause about just how watertight even the Dutch Protocol is. They observed that upon monitoring, some patients who transitioned under a strictly adhered to version of the Dutch Protocol appear to have substantial reproductive regret, body shame, and sexual dysfunction. In December 2022, these preliminary findings were presented by Dutch experts at the World Professional Association for Transgender HealthWPATH Symposium.

A common claim by Americans who oppose state restrictions on gender-affirming care for minors is that Sweden, Finland, the Netherlands, and the U.K. have not done away with hormonal interventions, and therefore lawmakers who seek limits are presumably going against what European health authorities recommend. Additionally, voices in America’s “affirmative-medicine” movement point to Europe not having bans on gender-affirming care for minors. It’s true that Europeans aren’t banning such care, and so legislators in the U.S. who pursue bans are contravening European recommendations. But this only tells part of an evolving and layered story.

At the risk of overgeneralizing, the American approach provides more autonomy to minors, in which the medical establishment’s role is mostly to affirm a child’s declaration that he or she is trans. This affirmative model immediately removes several of the guardrails put in place by, say, the Dutch Protocol, resulting in a possible deficient lack of medical “safeguarding.”

A growing number of nations in Europe are not practicing “gender-affirming care” for minors in quite the same way as America is. In fact, for several years, Europe has been moving in a different direction from the U.S., as Europeans exercise greater restraint when treating children with gender dysphoria. In essence, progressively the message emanating from European gender experts is that until there is reliable long-term evidence that the benefits of youth gender transition outweigh the risks, it is prudent to limit most medical interventions to rigorous clinical research settings.