Norway Takes a Step Forward in Ending “Experiment” in Youth Gender Medicine

Independent body finds the country’s affirmative approach risky, irreversible, and based on cherry-picked research.

An independent investigating body in Norway has called the use of puberty blockers, cross-sex hormones and surgeries in young people “experimental” and recommended that the authorities restrict such treatments to research settings until more evidence on their efficacy and safety is available.

The report, called “Patient safety for children and young people with gender incongruence,” was published on 9 March by an agency called UKOM (Norwegian Healthcare Investigation Board), whose mandate is to investigate “serious adverse events and other serious concerns” in Norway’s health system. 

UKOM conducted interviews with gender-distressed young people and their relatives, prompted by complaints about the care some young patients received. The report outlines several problems with the current state of transgender healthcare in the country, from the lack of data on safety and efficacy, to societal tension interfering with the ability to make sound decisions, to the over-emphasis on rights (rather than evidence) in the current guidelines.

Various actors in Norway are carrying out gender confirmation treatment, say the authors, though there is no national register of any kind of data. By classifying the treatments as experimental, they will be subject to stricter rules concerning informed consent, eligibility, and outcome evaluation. “This will contribute to safer and more predictable services,” according to the report, and will also contribute to an evidence base upon which future decisions can be based.

Gender care in Norway until now

The Rikshospitalet, or Oslo University Hospital, is home to the country’s centralised gender service. Like other Western countries, Norway has seen the number of young people seeking help increase dramatically since 2012, from 5–10 per year to nearly 200. Most of the increase is made up of young girls.

Since 2015, a guide published by the health directorate called “The right to the right gender,” which closely echoes WPATH’s SOC7 gender-affirming model of care, has been the blueprint for practitioners’ clinical decisions. Young people have had relatively easy access to gender-affirming care, with puberty blockers prescribed from tanner stage 2 of puberty, cross-sex-hormones from 16, and surgeries from 18 – with no psychological assessments.

The 2015 guidelines were drafted in the context of the new conditions for changing legal gender status in Norway, as the new legislation withdrew the requirement for transgender people to remove their reproductive organs as a prerequisite to altering the sex marker on their official documents.

In June 2020, the health directorate published new guidelines, written with the help of activists like the Patient Organisation for Gender Incongruence (PKI). (Bernard Lane, who spoke to an individual consulted as part of UKOM’s inquiry, said the country’s politicians and national health service had been heavily influenced by activists.)

A group of five professionals published an op-ed in the newspaper Aftenposten raising the alarm about the lack of evidence to justify the treatments recommended in the 2020 guide. “The new guidelines give the impression that sex-affirming treatment with hormones and surgery is well-proven. This is not correct. Such treatment methods, which have irreversible and significant consequences, have a weak knowledge base,” they told the paper. 

Paediatric psychiatrist Anne Waehre, who appeared in the Swedish “Trans Train” documentary, was one of the doctors who co-authored the op-ed. She later told the TV channel tv2 in 2022 that it is common for young people to have feelings of gender incongruence, “but not everyone should have medical treatment.” Dr Waehre, who works at the Rikshospitalet, said she feared that some children and young people would regret their treatments and would be stuck with irreversible consequences.

Parallel gender services – the HKS in Oslo

Complaints about the current state of care in Norway come from “several actors,” according to the UKOM report, “from the authority side and health personnel, and patient and family organisations, questioning the soundness and organisation of the treatment offer.” Indeed, activists and patient advocacy organisations have long complained about what they consider to be the gatekeeping nature of the centralised service at the Rikshospitalet.

It is widely known that a medical service funded by the municipality of Oslo called the Health centre for gender and sexuality (HKS) has been offering an alternative, more affirming, option to gender-distressed young people. HKS advertises itself as a treatment centre “for all people in Oslo between the ages of 0 and 30 who want to talk about topics related to LGBTIQ+,” with “special expertise in trans*, gender identity and sexuality.” HKS claims on its website to provide “gender-affirming support and treatment at a low-threshold level.”

In April 2022, the authorities launched an investigation into HKS and the service was later instructed to stop treating minors with puberty blockers and cross-sex hormones. One of its practitioners is a transwoman called Esben Esther Pirelli Benestad. Benestad, a sexologist and TV personality, was stripped of her licence to practise medicine in February this year after complaints that she violated professional standards. 

Benestad’s alleged violations include failing to refer gender-distressed young people to the Rikshospitalet and prescribing them hormonal treatments based on her own evaluations – and also for prescribing addictive drugs irresponsibly. One of Benestad’s patients had committed suicide after being treated with puberty blockers, having already been prescribed cross-sex hormones by the Rikshospitalet. 

However, despite Benestad being struck off and the unambiguous nature of the UKOM report, just like in Sweden, how the new recommendations will be implemented on the ground remains to be seen. The Society for Evidence-Based Medicine has reported that they will thoroughly review UKOM’s report, saying, “Currently, our assessment is that the UKOM report is akin to UK’s Cass Review in that it makes recommendations for restructuring youth gender services. How Norway’s NHS will implement these recommendations remains to be seen.”