Alberta’s sweeping changes to restrict medical transitioning for children are a first in Canada in the face of ever-increasing numbers of children surgically altering their bodies.
Before the province’s latest announced policies, a number of U.S. states had implemented bans on altering the bodies of minors—those under 18 years of age. As well, some European countries have introduced restrictions on the procedure for children.
In May 2023, Florida passed
legislation that bans gender-reassignment prescriptions and procedures for those under 18. The legislation also allows the state to step in and take custody of a child under 18 if there is concern that these gender-reassignment treatments are being used or will be used on the child.
The following month, Texas passed a
law that restricts health-care providers from performing gender-reassignment surgery on those under 18. They are also prohibited from providing or prescribing drugs that induce transient or permanent infertility, including puberty blockers meant to stop or delay normal puberty and hormone therapies meant to change a child’s body to that of a different sex.
Utah had also earlier, in February 2023, passed a bill that
prohibited transgender surgeries on those under 18 and prohibited hormone treatments to those minors not diagnosed with gender dysphoria before the bill was put into effect.
About 20 other U.S. states have bans or restrictions on transgender medical care for minors, according to a
review by Reuters published in August 2023. Among them Arkansas, Georgia, Idaho, Indiana, Iowa, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, North Carolina, North Dakota, South Dakota, Oklahoma, Tennessee, and West Virginia.
Some states are considering laws to allow individuals who were provided transgender medical care to launch civil lawsuits for medical malpractice.
In Hawaii, Oklahoma, and New Jersey, legislation has been introduced to require jail time for medical professionals who offer gender-altering treatment or procedures to those under 18.
Under
Alberta’s new policies introduced on Jan. 31, “top and bottom” gender reassignment surgeries are banned for those under the age of 18, while those under 16 will not be permitted to take puberty blockers or hormone therapies as part of gender reassignment treatment.
Those aged 16 and 17 will be permitted to take medications for gender reassignment “so long as they are deemed mature enough to make these decisions and have parental, physician, and psychologists’ approval,” Alberta Premier Danielle Smith said on Jan. 31.
United Kingdom
Many European countries have also been reining in treatments for those under 18 dealing with gender issues.In the
United Kingdom, gender-transition surgery is permitted only for adults and not for those under 18. Puberty blockers are only permitted, in addition to psychological support, if the patient has lasting signs of gender dysphoria and meets “strict criteria.” Cross-sex hormones are permitted from the age of 16 for teenagers who have been on puberty blockers for at least 12 months.
The National Health Service (NHS)
changed its policy over the past several years, first to ban access to gender-change surgery for teens and in 2023 to restrict access to transgender-care medications.
“Most treatments offered at this stage are psychological rather than medical,” the NHS website says on a page that addresses
treatment for gender dysphoria. “This is because in many cases gender variant behaviour or feelings disappear as children reach puberty.”
The U.K
ordered the shutdown of its transgender treatment clinic, Tavistock Clinic, after an independent report in 2022 said the clinic’s services were “not safe” for children.
The country’s health-care system is considering a minimum age for transgender treatment, saying there has not been such regulations, meaning that children as young as 4 have been referred to the clinic.
“For some people, this just seems too young, and they are concerned that it could result in unnecessary and inappropriate referrals being made,” NHS England said on its
website. “For example, we know that showing an interest in clothes or toys of the opposite sex or—displaying behaviours more commonly associated with the opposite sex—is reasonably common behaviour in childhood and is usually not indicative of gender incongruence.”
Other European Countries
Finland in 2020 shifted to relying more on psychotherapy rather than medications as the first-line treatment for youth struggling with gender issues, noted the Society for Evidence Based Gender Medicine (SEGM) in an
article in July 2021.
In 2022,
Sweden also began to pull back on medical interventions for children looking to change genders, following the move by Finland two years earlier.
While Finland still allows those under 18 access to puberty blockers and hormone medications, however, surgeries are not given to minors.
“The Finnish guidelines warn of the uncertainty of providing any irreversible ‘gender-affirming’ interventions for those 25 and under, due to the lack of neurological maturity,” the SEGM article said.
Sweden’s National Board of Health and Welfare decided to update its policy before the end of 2022 and advise against puberty blockers, surgery, and hormonal treatments before adulthood.
In Denmark, most youth referred for treatment would no longer get puberty blockers, hormones, or surgery, but therapeutic counselling and support instead. Genital surgeries for minors are disallowed in Denmark, and mastectomies may also be officially disallowed in updated treatment guidelines.
The changes follow research that found a substantial increase in youth seeking transgender care after Denmark opened a centralized gender transition service for minors in 2016.
“In Denmark, the number of referred persons has increased from 97 in 2016 to 352 in 2022, of which birth-assigned girls aged 11-18 make up 70 percent,” a Danish-language
paper published on July 2023 in the Journal of the Danish Medical Association said, reported SEGM.
Due to the increased restrictions on eligibility for hormone interventions, just 6 percent of the referred youth were transitioned in 2022, compared to 65 percent in 2018, SEGM said.
In the Netherlands, there has been growing medical, legal, and cultural debate since 2023 about the availability of transitioning treatments for youth, as guided by the 2018 Dutch Protocol, which did away with many of the eligibility restrictions in the original Dutch protocol.
This debate is important as the country is both the birthplace and international centre of expertise for the practice of youth gender transitions, says a November 2023
SEGM article.
The discussion kicked off following a paper in a Dutch medical journal, a paper in a Dutch legal journal, and a documentary by a Dutch public broadcaster that delved into the protocol and treatments in the Netherlands.
However, how the country treats gender-dysphoric minors has stayed the same.
“Acknowledgment of the weak evidence base and the changing population base has not resulted in an official change in treatment approaches,” the SEGM article said.
Rise of Transgender Treatments
According to an
industry analysis by India- and U.S.-based
Grand View Research, the U.S. sex-reassignment surgery market was estimated at US$2.1 billion in 2022 and is expected to grow at a compound annual growth rate (CAGR) of 11.25 percent from 2023 to 2030.
“The rising prevalence of gender dysphoria and the increasing number of individuals in the U.S. opting for gender affirmation surgeries are expected to boost market growth over the forecast period,” the analysis found.
Numbers
compiled by Komodo Health for Reuters show that the number of minors across the United States who received a diagnosis of gender dysphoria nearly tripled between 2017 and 2021.
In 2017, 15,172 children and teens between the ages of 6 and 17 in the United States were diagnosed with gender dysphoria. By 2021, that number had grown to 42,167.
The data show that “top surgery” to remove breasts is more common among teens than other types of transgender surgery.
From 2019 to 2021, at least 776 mastectomies, the surgical removal of breasts, were performed in the United States on patients ages 13 to 17 with a gender dysphoria diagnosis. The information is based on insurance claims and does not include treatments that were privately paid for.
Naveen Athrappully, Lily Zhou, and Reuters contributed to this report.
