Sweden is tightening, Norway is going the opposite way – NRK Trøndelag
– The new Swedish guideline involves a radical reorganization of previous practice, says Pål Surén.
He is a pediatrician and researcher at the National Institute of Public Health.
The Norwegian rules for treatment with puberty blockers and sex-confirming hormones was updated in 2020.
Psychiatric examination before start-up is no longer a requirement for children and young people. Those over the age of 16 should be able to receive hormones without parental consent. And more offers will be created around the country.
This is similar to how the recommendations were in Sweden in the past. But after a thorough review of research in the field, the Swedes suddenly went in the exact opposite direction in February this year.
The main reason is uncertainty about a patient group that has become much larger in recent years.
One group stands out
In ten years, there has been more than a doubling of children and young people in Norway and Sweden who want gender-confirming treatment.
These have what is called gender dysphoria. That is, they experience a strong discomfort with living with a body that does not match their gender identity.
In the past, it was mostly those who had known since childhood that they were “born in the wrong body” who received puberty blockers and later estrogen or testosterone. This group still exists.
Men according to The National Board of Health and Welfare there is a completely different group that is growing rapidly: Biologically born girls from 13 to 17 years who experience gender dysphoria only in adolescence.
In 2015, the amount was in this group 107 people in Sweden. In 2018, there were 233. No other group has grown so much, so fast.
The National Board of Health and Welfare writes in one new report that they can not explain. They believe there is too little knowledge about what treatment is appropriate to give to teenagers who seek help.
They are worried about that too Puberty blockers have side effects we do not know about.
The conclusion is that the risk is greater than the benefit of giving puberty blockers and sex-confirming hormones to patients under 18 years of age.
In Sweden, exemptions should now only be given in style cases, or to patients who are involved in research. Everyone should now receive psychosocial support before they receive any other help.
Difficult gray areas
– The criteria for receiving treatment are more clearly linked to the fact that gender incongruence must have debuted in childhood. It must have stuck to puberty, and puberty has been perceived as mentally stressful, he says Thomas Lindén, head of department at the National Board of Health and Welfare.
Parts of the professional community in Norway have the same concern as the Swedes, according to chief physician Anne Wæhre.
She leads the team for gender incongruence in adolescents (KID team) at Rikshospitalet in Oslo. They also experience that the patient group that clearly increases the most are biologically born girls.
According to Wæhre, there are great differences between the individual patients in the group. Most have not expressed gender incongruence when they were young. Noen hair maybe been a little insecure.
– Parents can, for example be occupied by that their children have been «boy girls». That is what is so difficult in the clinic. These are gray areas, says Wæhre.
The Swedish report also shows that many of the teenagers who seek help have other challenges than gender dysphoria. Such as depression, anxiety, ADHD and autism diagnosis. At Rikshospitalet they see the same thing.
But the main reason why the Swedes are now turning is the danger of detransition and possible remorse, explains Thomas Lindén at the National Board of Health and Welfare.
Will anyone change their mind?
Detransition means that someone who has undergone hormone treatment and possible surgery, changes his mind and wants to return to his biological sex.
– The knowledge that gender-confirming treatment sometimes leads to impaired health and quality of life, or injury in young adults, is one of the factors that has been important for our assessment, Lindén says.
Few studies have been done on detransition. Lindén can not refer to concrete figures – only stories about young Swedes who have regretted. He believes that these individual stories, which had not been heard of a few years ago, are more than enough to step on the brakes.
Emelie Köhler is one of those who has such a story. She thought life would be better as a boy.
Wish she had more critical questions
She has even finished treatment.
– It was a tedious process for me. And I was also an adult, says Köhler in the NRK program Public information.
Today she runs a website about detransition. She started it because she thought it lacked information that matched reality.
– Some of those I come in contact with today are 20 years old. They went much further than what I did, and only have friends within the environment.
As a young transgender person, she wished she had more critical questions.
– I had learned from day one that everyone was born with an inner gender, and that it is linked to the “I-one” and is above biology. It was almost hammered in as pure facts in society. I needed someone who was critical of the whole concept. Who talked about that you do not have to feel like something, to be.
Anne Wæhre at Rikshospitalet says there are not many like Emelie in Norway.
– We know very few who have wanted to stop initiating hormone therapy. This is something we take very seriously.
Who should receive treatment?
Different professional environments have totally different opinions about who should receive treatment with puberty blockers and sex hormones.
The doctors at Rikshospitalet only give medication to children and young people who have undergone a thorough psychiatric assessment.
– We give puberty blockers exceptionally to some patients, says Wæhre.
They provide such medications to between zero and 10 patients a year.
– Why are you restrictive?
– We know too little, simply.
On the other side is the Health Station for Gender and Sexuality (HKS).
Moral panic
– I experience what is now happening in Sweden as moral panic, says Ingun Wik.
She is the department head at HKS. The health station is run by Oslo Municipality, and they are particularly concerned with gender diversity and sexuality.
Last year received six patients puberty blockers with them. HKS sees the effect as “a time out” – a pause for thought for a child who experience a lot of stress associated with having to go through puberty with the wrong sex.
Around 100 patients at HKS received sex-confirming hormones last year.
At the national service at Rikshospitalet, 109 young people received the same in 2020. The number for 2021 is not clear, but is expected to be fairly similar. 270 adults received sex-confirming hormones at Riksen in 2021.
In the past, Wik has encouraged Norway to look at how people with gender incongruence are treated in Sweden, because they were based on the most up-to-date research. But now that the Swedes have reviewed the research again, Wik will no longer recommend looking at them.
– I hope we in Norway manage to distance ourselves from what is happening in Sweden, and comply with international guidelines.
Do not recognize
According to Wik, they do at HKS interdisciplinary mapping and have expectations clarification with patients before treatment begins. But they do not demand psychiatric investigation.
The health station will be easier to get treatment.
– For many, it is necessary to be able to live a good life, says Wik.
Wik does not recognize himself in the large increase in biological teenage girls who experience that they are boys, as the Swedish authorities and Rikshospitalet report.
She thinks it is very serious if it becomes more difficult for this group to get help to take a place like themselves.
– We as health workers can not decide if someone is trans enough to get treatment, says Wik, who is critical of what demands the team at Rikshospitalet should make on patients.
Will not pay attention to the changes
Aleksander Sørlie is the outgoing leader of the Patient Organization for Gender Incongruence (PKI). He is critical of the fact that the Swedish changes are receiving attention in Norway.
– First and foremost, I think that the focus on the details in other countries’ guidelines or practices is a derailment from what is actually important: How we can ensure a good and sound health service here in Norway, he writes in an e-mail to NRK.
He further writes that the PKI is concerned about changes that are dragging other countries in what he calls a more trans-hostile direction.
At the same time, he believes that what is written on paper is not always practiced in reality.
– It is a problem when the media and health authorities in Norway emphasize such cases so early in the process, because we experience that the media rarely follow up on such cases, and therefore do not receive important updates.
The Norwegian Directorate of Health: – We know that we know too little
In the Norwegian Directorate of Health, they have familiarized themselves with the new and much stricter Swedish recommendations.
– I think we are quite restrictive in Norway, but not so restrictive, says division director Johan Georg Torgersen.
The Swedes now believe that the risk associated with detransition is more clearly documented, and also consider that the uncertainty surrounding the side effects of puberty blockers and sex hormones is great. This is little affected in the Norwegian guideline.
– On the one hand: We know we know too little. We would like to have more knowledge about this. On the other hand, this is a patient and user group that actually exists, which has rights and requirements for health services. We must also take this into account.
Torgersen has noticed that there has been a large increase among biological girls in their teens who want treatment.
– We are well aware this group has increased. We would like to have even better knowledge to become even more confident in the advice given.
The division director will not follow up with the Swedes regarding the requirement for a psychiatric assessment until young people are offered puberty blockers or sex hormones.
– Oh make it a requirement for the whole group, we believe violates the principle that everyone must be assessed individually as needed. Gender incongruence is not a psychiatric disorder.