European Countries’ Restrictions on Gender Treatment for Minors Contrast Sharply With US Push

Citing serious health risks and a lack of supporting evidence, Sweden, France and England have all adopted a more critical stance toward ‘gender-affirming care’ for youth — a stark difference to the approach taken in many U.S. states and cultural institutions.

Transgender flag is displayed during a parade in Barcelona, Spain, on July 15.
Transgender flag is displayed during a parade in Barcelona, Spain, on July 15. (photo: Davide Bonaldo / Sipa via AP)

At both the federal and the state level, and in the American culture more broadly, there is a concerted effort to remove obstacles to minors’ access to controversial “gender-affirming care.” 

California, Minnesota and New York have passed legislation establishing their state as a “trans youth refuge,” while the federal government is challenging the legality of state-level restrictions placed on practices like hormone therapy and “sex-reassignment surgery.” Even an academic journal was pressured into retracting a study on “rapid-onset gender dysphoria” after pushback from activists.

In Europe, however, a trend in the opposite direction is unfolding. Judging that the scientific evidence is lacking, that long-term effects remain unknown and that the benefits are outweighed by the risks, governments and health authorities in at least five countries — several of which pioneered in “gender-affirming” hormonal and surgical treatments for minors — seem to be reexamining their decisions.

What’s more, in a letter published in The Wall Street Journal on July 13, clinicians and researchers from nine countries, mainly European, stepped forward to criticize the recently made statement by the president of the American-based Endocrine Society, according to whom “gender-affirming care improves the well-being of transgender and gender-diverse people.”


‘The Risks Outweigh the Benefits’

Considered by many progressives as model societies, the Nordic countries have long been recognized as frontrunners in the transgender-rights movement. In 1972, Sweden became the world’s first country to provide free hormone therapy and permit individuals to change their legal gender after undergoing “sex-reassignment” surgery. Fifty years later, however, the country made a surprising shift, choosing to head in a substantially different direction.

It all started in the autumn of 2018, when the Swedish government introduced a new proposal aiming to lower the minimum age for gender-reassignment treatments from 18 to 15, eliminate the requirement for parental consent, and permit legal gender changes for children as young as 12.

The proposal was heavily criticized by psychiatrists and labeled as “a big experiment on children.” Sparking a social-media backlash, the proposal was eventually withdrawn. After reviewing the scientific evidence on the subject, the Swedish Agency for Health Technology Assessment (SBU) concluded that there was in fact no evidence for the safety or efficacy of the “gender-affirming” treatments.

“While we have no evidence for the efficacy of the treatments, we have a lot of evidence for big health risks,” Sven Román, a Swedish consultant psychiatrist working in child and adolescent psychiatry who signed The Wall Street Journal letter, told the Register. 

“Almost every prepubescent child who receives hormone therapy will become infertile, and their bone density will be severely affected,” Román said. “For example, one clinic in Stockholm treated a young boy who had transitioned to a girl, receiving hormone therapy from a very early age. After a couple of years, when the boy had decided to detransition, his skeleton was like that of an 80-to-90-year-old man. This is irreversible damage.”

In February 2022, the Swedish National Board of Health and Welfare, known as Socialstyrelsen, changed its clinical practice guidelines and regulations with respect to “gender-affirming care” for minors, after having formerly recommended the use of puberty blockers, described as “safe and secure,” since 2015. 

Socialstyrelsen’s new recommendations underlined that the risks involved with hormone therapy outweighed the possible benefits. According to the agency, “the scientific evidence is insufficient” to draw conclusions on the effects of puberty blockers, cross-sex hormones and “gender-affirming” surgeries and announced that such treatments should be given only in a research context or under exceptional circumstances.  

According to Román, hormone therapy has not only been shown to affect individuals physically, but also cognitively and psychologically: The evidence, which indicates risks extending beyond infertility, osteoporosis and blood clots to include delayed or arrested neurological development as well as depression, anxiety and suicidal thoughts, is rapidly growing and undisputable.

“The truth is that we have no idea what the long-term effects of these treatments are,” Román said. “It is all a big experiment.”

“These findings show these ‘therapies’ for what they really are, that is, serious and big medical interventions that can lead to grave and permanent consequences,” Samuelle Falk, a psychiatry resident at North Stockholm Psychiatry and Ph.D. student at Karolinska Institutet in Sweden, told the Register. “It is also an indication that sex-reassignment therapy might not be the right answer after all.”


Gaps in the Evidence

Only three days after Sweden changed its guidelines, the National Academy of Medicine in France issued on Feb. 25, 2022, a press release cautioning medical practitioners about the use of puberty blockers. 

Reminiscent of Karolinska University Hospital’s decision to ban the use of hormone blockers, the National Academy wrote that, “if France allows the use of puberty blockers or cross-sex hormones with parental authorization and no age limitations, the greatest caution is needed in their use, taking into account the side-effects such as the impact on growth, bone weakening, risk of sterility, emotional and intellectual consequences and, for girls, menopause-like symptoms.”

Emphasizing the irreversibility of “gender-affirming” surgeries, the National Academy further warned about the growing number of young individuals wishing to “detransition.”

In addition to the health risks mentioned by Román and the French National Academy of Health, recent European-led studies published in the peer-reviewed American Journal of Psychiatry and the Journal of Clinical Endocrinology and Metabolism have shown there are no psychological benefits to either hormone therapy or “sex-reassignment” surgeries and that the discontinuation rates for hormone treatments are as high as 30%.

In a similar fashion, after concerns that children were too quickly referred to hormone therapy at the Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust, an English government report recognized in October 2022 that there were gaps in the evidence base for the efficacy of hormone therapy and thus insufficient evidence to discern the correct clinical approach and appropriate management of children and adolescents with gender dysphoria. 

Following the report, the nation’s only clinic specializing in pediatric gender medicine received orders to close its doors. Now, puberty blockers are only given to minors “in the context of a formal research protocol” in England.

Besides the renowned Bell v. Tavistock case in which Keira Bell took the Tavistock Clinic to court to argue that she had been unable to give proper consent to puberty blockers as a minor, the Christian Medical Fellowship in England further told the Register that many have also argued that “children with comorbidities — autism, behavioral difficulties, or who had suffered physical or sexual abuse — had those underlying issues sidelined and that the medical pathway inaugurated by puberty blockers was the main ‘treatment route’ for children and young people.” 

This resonates with the experience of Sven Román, who said, “I have worked with many children diagnosed with gender dysphoria, and every child has had at least one additional psychiatric disorder, often several ones. The most common psychiatric condition is autism or other autism-like conditions, which two-thirds of the children are diagnosed with. We need to study these connections more.”

After recognizing “gender-reassignment” treatments for minors as “an experimental practice” since most effects are unknown, Finland’s Council for Choices in Healthcare also reported in 2020 that gender dysphoria did not diminish after hormone therapy; instead, the therapy was accompanied by a range of potential risks, including possible disruptions in bone mineralization.

Concluding that “as far as minors are concerned, there are no medical treatments that can be considered evidence-based,” Finland recommended restricting access to puberty blockers and cross-sex hormones and completely prohibiting surgeries for minors. 

“The Finnish guidelines outline that the first line of intervention must be psychosocial,” Riittakerttu Kaltiala, a professor in neuropsychiatry at Tampere University in Finland who also signed the letter in The Wall Street Journal, told the Register. The treatment of any existing mental disorders must also be prioritized, she added. 

“Europe is on the right track,” the Finnish professor added. “Medical practices have to be based on solid medical evidence, and if such evidence does not exist, that is a reason to be cautious.”


A Contrary Approach in the US

According to a study by the organization “Do No Harm” in January 2023, the United States is the “most permissive country” when it comes to gender-affirming treatments. 

“As in many controversial bioethical issues, the U.S. is often polarized according to party lines,” Legionary Father Michael Baggot, assistant professor of bioethics at the Pontifical Athenaeum Regina Apostolorum in Rome, explained to the Register. “It would be unfortunate for care for people with gender dysphoria to remain just one more partisan issue.”

“This field of medicine is very politicized in the U.S.A.,” Finnish professor Kaltiala concurred, “but medicine has to follow the path of medical evidence, not that of political pressures.” 

The situation is somewhat different in Europe, where countries have been using the Dutch protocol as a reference point since the 1990s. The protocol, developed by the Center of Expertise on Gender Dysphoria in Amsterdam, establishes criteria for pharmacological and surgical interventions based on persistent gender dysphoria, absence of psychiatric conditions and informed consent and emphasizes the importance of psychotherapeutic support.

“Countries like Finland and Sweden have so far been especially cautious in applying the protocol rigorously and have been likewise bold in calling attention to failures to adhere to such standards,” Father Baggot said.

While European countries continue to urge cautious approaches to “gender treatments,” the United States has chosen to prioritize the so-called “affirmative model,” Father Baggot added, a model that, granting patient requests without too many obstacles, appears to align with what he called the absolutizing of bodily autonomy in American bioethics. 

Peter Vankrunkelsven, professor emeritus at the Catholic University of Leuven, who also signed the letter in The Wall Street Journal, likewise commended Sweden and Finland for their cautious approaches. 

With regard to the more permissive approach of the United States, Vankrunkelsven explained to the Register, “I believe that a lot of scientists and politicians, although concerned, are not daring or willing to take a firm position because they fear that they might be labeled as transphobic or discriminating.”

In addition to the lack of scientific evidence for the efficacy and safety of the treatments involved, Father Baggot cited other aspects that may have factored into the European trend towards a more cautious application of the Dutch protocol: fear of expensive legal lawsuits and the recognition that the treatments fail to offer the promised peace and integration in patients.

In contrast to risky, ineffective procedures for those experiencing gender dysphoria, Father Baggot emphasized the imperative to provide “psychological and spiritual support needed for the person to come to a deeper integration with his or her biological sex.” 

 “Unfortunately, so-called gender-affirming care is often biological-sex-denying care,” the bioethics expert explained. “The approaches tend to treat the body as a malleable external instrument of a mysterious inner self.” 

“Many teenagers don’t like their bodies and all the changes happening to them during puberty, but that is normal,” Román added, stressing that any experience of bodily discomfort before or during puberty must not be confused with gender dysphoria, although it increasingly is.

Father Baggot said that instead of children feeling pressured to attempt radical alterations of their bodily sex, “they should be taught that there are many valid and beautiful ways to live their masculinity or femininity” — something that, for the time being, seems more possible in progressive European countries than in similarly progressive American states. 

“I hope that Europe’s greater caution in subjecting vulnerable children to risky experimental procedures inspires a new perspective in the United States,” he said. “I doubt that this will happen unless partisan politicians can work past inflammatory rhetoric to find common ground on offering compassionate and science-based care.”