Alberta Premier Danielle Smith says she’s taking cues on her controversial new transgender policies from Europe, so what are other jurisdictions doing to change how young people access gender-affirming medical treatment?
Smith announced the suite of policies on Jan. 31, including a ban on puberty blockers and hormone treatments for children under 16 — except for those who have already begun therapy. She also plans to ban gender-affirming “top” surgeries for minors — a procedure carried out by eight young trans people in Alberta in 2023.
Her education plan to require parental consent for kids under the age of 16 changing their names or pronouns at school follows the same new rules Saskatchewan and New Brunswick made last year, but has drawn criticism for going further, requiring parents opt-in on formal lessons on sexuality and gender identity.
When asked about the impetus for her new proposals, Smith has repeatedly pointed to moves being made in European countries.
“We’ve been watching internationally as the U.K. has made policy changes as well as Denmark, Norway, Finland, Sweden — this has been an ongoing conversation over the last number of years,” she said on Feb. 1.
It’s true that the countries Smith cites have taken a second look at their medical guidelines for gender-affirming care for young people amid a surge in demand for treatment, and many have noted a need for more caution, along with more long-term medical research.
However, they aren’t legally banning treatment for minors in the same way some U.S. state legislators have, and are instead letting health authorities lead the conversation in revising medical guidelines.
The U.K.
Like Smith, Health Minister Adriana LaGrange has pointed to developments in Europe, including the U.K., as inspiration.
“They’re already having conversations and implementing many of these because they’ve been further along this road than we have been, so we’re learning from what has already occurred in other jurisdictions,” LaGrange told Postmedia.
In England last year, the National Health Service in England announced that gender identity clinics will have to operate under stricter eligibility guidelines after a review cited a lack of research-based evidence.
Last June, the NHS said that puberty suppressing hormone treatment for children and adolescents will only be newly prescribed as part of clinical research — except in exceptional circumstances.
The NHS has delayed its plans to close the Gender Identity Development Service (Gids), based at London’s Tavistock and Portman NHS Foundation Trust until March — but it will be replaced by at least two regional hubs. NHS England has said the rationale for Tavistock’s closure was that it had not been able to keep up with demand or provide the level of appropriate care.
Smith, speaking to CTV News earlier this month, wrongly said Tavistock was closed.
Norway
The Norwegian Healthcare Investigation Board, an independent government agency, last year also flagged a lack of research-based knowledge about gender-affirming treatments, and called for national guidelines to be revised. That revision has yet to happen.
Torunn Janbu, department director in Norwegian Directorate of Health, told Postmedia the board has no authority to change guidelines or regulations.
Janbu said the country does not prohibit gender-affirming treatment for children, and the Directorate of Health, which is responsible for developing national guidelines for the health sector, is working to improve health care for trans people.
According to the country’s guidelines, minors 16 and older can generally receive medical treatment without parental consent, including puberty blockers. Potentially irreversible hormone therapy, however, does require parental consent.
There is no law prohibiting gender-affirming surgeries. For those under the age of 18, chest surgery “may be appropriate” in special cases, based on a comprehensive interdisciplinary assessment and parental consent, Janbu said.
“It will be up to the clinical communities to decide whether hormone therapy, or parts of the treatment, can be offered by the regional centres.”
Sweden
As in Canada, 18 is the legal age in Sweden, where the National Board of Health and Welfare’s guidelines, last updated in 2022 and available in English, reported a lack of evidence on hormonal and surgical treatment for minors, recommending that puberty blockers, hormone treatment, and mastectomy “can be administered in exceptional cases.”
Urging caution, it said “the risks of puberty blockers and gender-affirming treatment are likely to outweigh the expected benefits of these treatments” for youth.
Spokesperson Anders Berg told Postmedia those 2022 guidelines are recommendations, not strict legal rules.
The board also emphasized the need for health regions to solve accessibility problems and build up more knowledge about the results of treatments.
Finland
Finland’s Council for Choices in Health Care (COHERE), a public body that recommends treatments for public funding, has called the medical transition of minors an “experimental practice” and, like England and Sweden, prioritizes psychosocial support as the first step when young people seek treatment.
“Puberty suppression treatment may be initiated on a case-by-case basis after careful consideration and appropriate diagnostic examinations,” it said in a 2020 summary published in English.
In an email to Postmedia, COHERE spokesperson Hanna-Mari Jauhonen confirmed that 2020 guidance is still current, and referred Postmedia to Riittakerttu Kaltiala, adolescent psychiatry professor at Tampere University’s faculty of medicine and health technology.
Kaltiala told Postmedia puberty blockers are not forbidden, but they are rare. She noted the 2020 national guidelines did not restrict the use of hormonal interventions for minors, but pointed to developments in Sweden, Norway and the U.K.
“Given that latest systematic reviews demonstrate little — if any — benefits of the early intervention halting pubertal development in its early stages, and concerns about negative side-effects are increasing, practices are currently growing more and more conservative,” Kaltiala said.
Denmark
Denmark too has been cited as a jurisdiction moving towards “a more cautious approach to hormone therapy” until more evidence emerges. A 2023 study published by the Danish Medical Association, which represents doctors, calls for more research, particularly about why, and how often, hormone treatment is discontinued.
However, according the latest 2018 Danish Health Authority’s guide to gender identity health care, there is no minimum age requirement for “hormone blockers,” and the decision to get treatment can be made by a young adult over 15 even if parents disagree. In “exceptional cases,” referral for breast surgery may be offered, but other surgery can’t be offered to those under the age of 18.
Danish Health Authority spokesperson Lotte Bælum told Postmedia that the guide is under revision and will be updated this year.
The U.S.
While neither Smith nor LaGrange have explicitly pointed to what is happening south of the border, Republican-led states have enacted laws similar to those being proposed by Smith, including banning specific medical treatments for youth, restricting trans participation in sports, and requiring parental consent for schools to use preferred names or pronouns.
Some of the legislation restricting gender-affirming medical treatment, including bans on puberty blockers, hormones, and surgery, across the U.S. came with penalties on physicians that range from revoking medical licences, to felony charges, which can carry a prison sentence.
Major medical associations in the U.S., including the American Academy of Pediatrics and the American Medical Association, have opposed restrictions to trans health care access.
In 2023, the American Civil Liberties Union (ACLU) counted 84 anti-LGBTQ bills across the United States that were passed into law, including 26 that restricted access to medical treatment for minors — although some are being challenged in court.
Last August, Global Affairs Canada issued a new travel advisory for LGBTQ travelers visiting the U.S., noting some states had “enacted laws and policies that may affect 2SLGBTQI+ persons.” No specific states are listed, but the federal website directs travellers to check the relevant state and local laws.
Doctors with the Canadian Paediatric Society and the Alberta Medical Association have said Smith’s proposed rules will increase the risk of harm, mental health issues, and suicide among already vulnerable youth.
lijohnson@postmedia.com
