Doubt in Denmark

Another progressive country is having second thoughts about paediatric gender transition

An artwork part of the Roskilde Festival in Copenhagen appeals for a precious commodity. Photo by Zuzana Ruttkay on Unsplash

Denmark has taken a step towards caution in gender care by offering a form of counselling rather than medical treatments to the main patient group of teenagers with no childhood history of distress in their birth sex.

Official acknowledgment of a change in treatment policy was given on May 31 by the Liberal Party Health Minister Sophie Løhde during parliamentary debate of an unsuccessful resolution seeking a total ban on medical transition of minors.

Ms Løhde said that medical treatment at the Danish central gender clinic in Copenhagen—the Sexology Clinic—would only be offered “if the child or young person has had gender dysphoria since childhood.”

“If the gender dysphoria has started in connection with puberty, the young person may, among other things, be referred to a process of reflection or clarification,” she said.

“This process is often finalised without medical treatment, as the indication for treatment is not considered present.”

The dominant patient profile internationally is adolescent-onset dysphoria, chiefly affecting females, but the (limited and contested) evidence base for puberty blockers and cross-sex hormones for minors mostly derives from past studies of classic early childhood-onset dysphoria typically among males.

Gender distress that appears at or after the onset of puberty, often following online immersion and transgender identity declarations among school friends, is commonly referred to as Rapid-Onset Gender Dysphoria (ROGD) following the 2018 preliminary study of American public health researcher Dr. Lisa Littman.

Dr. Littman’s work is well known in Nordic countries. Sweden’s National Board of Health and Welfare last year referenced her 2021 detransitioners study and declared that the very low rate of treatment regret claimed by youth gender clinics “no longer stands unchallenged”.

Sweden and Finland are the most advanced in the post-2019 Nordic shift to caution, while health authorities in Norway are under pressure after the country’s independent healthcare investigation agency declared in March that medicalised gender change for young people was “experimental” and should be confined to clinical trials.

Systematic reviews of the evidence base undertaken in Finland and Sweden showed it to be weak (as did reviews in the United Kingdom).

“[Although in Denmark’s parliament] the issue of gender reassignment for children and other identity policy topics seems strongly divided into blocs, we feel that this is by no means the case in the general population, when the seriousness of the matter finally dawns on people. Many simply did not know that this was happening”—Danish Rainbow Council post, 2 March 2023

Denmark’s point of difference is that the call for an end to medical transition of minors is being spearheaded by a mainstream LGBT group, the Danish Rainbow Council, launched in 2022 under the leadership of transsexual Marcus Dib Jensen. The organisation is pledged to child safeguarding and recognition of gender dysphoria as a mental disorder, while opposing the extremes of gender ideology.

In May’s parliamentary debate, Minister Løhde faced pointed questions on gender medicine from politicians Mette Thiesen and Mikkel Bjørn, both members of the populist Danish People’s Party.

The minister presented the treatment policy change as an evolution influenced by developments in the field and clinical judgment. She was not specific about which medical treatment was being withheld from patients with adolescent-onset dysphoria (or ROGD), nor the timing of the policy change.

She noted that the Sexology Clinic had “become more reluctant to offer hormone treatment” to young people.

“This reluctance manifests itself particularly regarding young people with gender dysphoria that arises in connection with puberty.

“I think it is a positive thing that there is [such] a response to research and experience… both in Denmark, but also abroad, which we must follow closely. And this knowledge and experience lead to adjustments in the current treatment options.”

The group LGBT+ Danmark, whose slogan is “Global Queer Solidarity” and which campaigns for “better gender-confirming treatment”, told GCN that the minister’s remarks referred not to a change in general treatment guidelines but to “an adjustment in the practice” of the Sexology Clinic last year.

GCN put questions to the clinic and to Denmark’s health ministry.

Video: “You can be uncomfortable with reality, but it doesn’t change reality”—Marcus Dib Jensen, chairman of the Danish Rainbow Council

Big change

A recent commentary article on the minister’s remarks posted by the Danish Rainbow Council’s deputy chairman Jesper W. Rasmussen said:

“It is important to understand how significant it is that as many as 80 per cent of the children who previously underwent gender reassignment surgery will now, in the minister’s own words, no longer be able to undergo this controversial, irreversible treatment.

“Since [the minister’s comments], we have received several emails from relieved parents of ROGD children, and in the coming months we will keep a close eye on whether these children continue to be free from hormonal sex reassignment.

“We will do this by regularly requesting access to the treatment statistics from the Sexology Clinic [at the specialist hospital Rigshospitalet].”

The resolution for a total ban, put up in March by the populist New Right party after all other members of parliament had ignored apolitical appeals from the rainbow council, was not expected to pass in the government-controlled chamber.

But the council argued that the result was significant because public debate had been unleashed and the authorities were put under pressure.

The council suspected that the de-medicalisation of adolescent-onset (or ROGD) cases had been enacted without formal announcement in 2022, thereby explaining a sharp decline that year in the number of minors undergoing hormonal treatment.

Roughly 80 per cent of the 341 minors who had undergone medicalised gender change from 2015 to 2022 were believed to be in the ROGD category, the council said.

Since 2015, when Ms Løhde was also health minister, minors have been able to undergo irreversible medical gender reassignment without parental consent from the age of 15.

“A top [American] pediatric psychiatry organization has nixed at least three panels with leading European psychologists about Europe’s move away from chemical interventions for children with gender dysphoria, raising questions about the politicization of American medicine and underscoring a clinical divide between the United States and much of the world”—Aaron Sibarium, news report, The Washington Free Beacon, 11 August 2023

Future unknown

In 2021, Sexology Clinic consultant Dr. Mette Ewers Haahr gave an interview to the Dagbladet Information media outlet in which she acknowledged “a lack of research” relevant to today’s mostly teenage female patients and her concerns about why these girls wanted to change gender.

“We see that treatment helps young people in the short term. But we lack knowledge about what happens in ten and 20 years. Or when they want to have children. What happens when they fall in love and start to have an active sex life?” Dr. Haahr said.

“Transgender young people assigned female have, for the most part, no active sex life. Not even with themselves. How will their sex life develop and does this affect their perception of their gender? We have sometimes seen in young people that gender and sex life interact and change together.”

Dr. Haahr’s comments about the weak evidence base prompted the rainbow council to ask why the authorities had allowed such a confident regimen of paediatric transition to begin in 2015.

“As adults, we must dare to step up and say stop this madness. We castrate and sterilise children and physically destroy their otherwise healthy bodies to alleviate a psychological discomfort that is usually temporary and, if not, can be treated with a sex change on the other side of puberty,” the council’s June 2 comment said.

Substack: Writer Mark Perrino, an American in Elsinore, takes the pulse of the ever-happy Danes

Breaking news: Men aren’t women

No surgery on minors

In May’s parliamentary debate, Minister Løhde also said that under new referral guidelines, it would no longer be permissible to offer transgender surgery such as mastectomy to children under age 18—“an option that, by the way, has never been used in Denmark.”

She said the country’s “entire guidance on health care for individuals with gender identity issues” was being reviewed.

GCN asked the Danish Health Authority if a systematic review of the evidence base would be undertaken.

A spokeswoman for the authority said: “We are in the process of updating the existing guideline and we will consult leading experts in that revision.”

In a post on a Danish study dealing with trans identity and suicide attempts, the Society for Evidence-Based Gender Medicine (SEGM) said:

“It remains to be seen whether the Danish Health Authority will take a cautious approach to the treatment of gender-dysphoric youth like the growing number of their European counterparts, or whether Denmark will choose to align with the current direction supported by a number of U.S. medical societies that assert that medical gender transition should be widely available for all youths who desire it.”

Copenhagen psychotherapist and former teacher Lotte Ingerslev, who writes the blog Transgender: the Fine Print and is a member of SEGM, told GCN that the Danish health minister’s May 31 remarks were “very, very important.”

She said the minister had represented this policy shift “as simply a result of the doctors ‘following the evidence’, and not a complete and utter break with their previous approach.”

Ms Ingerslev said this appeared to be a government tactic for “evading responsibility for the utter disregard for children’s bodies and lives.”

Nonetheless, she said the policy change meant “that teenagers will no longer be able to expect to get hormones as a quick fix for their loneliness, autism or inner homophobia.”

But she said these concessions to caution by the government and the Sexology Clinic were not enough and “the transing of children needs to be stopped completely.”

“Otherwise, the general public, schools, day-care centres and parents of gender-non-conforming children get a message from the state saying that gender-non-conformity is a sign that a child is ‘trans’, which goes against all evidence,” she said.

Opt-out females

In her 2021 media interview, the Sexology Clinic’s Dr. Haahr wondered aloud about why female patients are disproportionately represented in gender clinic caseloads.

She worried that for some girls, transition was more about “opting out of the feminine than opting into the masculine”, and more to do with physical discomfort than a different gender identity.

“When the birth-assigned girls reach puberty and their bodies change, some of them start to have these thoughts. Maybe the outside world has started to react differently to them because their bodies are suddenly sexualised,” Dr. Haahr said.

“They may not get as much speaking time, they’re belittled if they take up too much space, and certain girl things are expected of them that they can’t identify with. And then they feel really, really bad about their feminine bodies.

“Unlike the children [with early-onset dysphoria], who have experienced themselves as a different gender for as long as they can remember, we see that some of the [teenage] girls… have only had these thoughts for six months and are determined that they need body modification treatment. And then it becomes really difficult to figure out what it’s all about and what the right thing to do is.”

She said she paid particular attention to whether these girls had suffered traumatic experiences such as bullying, assault or sexual abuse.

“Abuse during adolescence and childhood can lead to alienation from one’s body. That’s where we need to be extra vigilant.”

She said today’s teenage female patients sometimes used formulaic language seemingly not their own when explaining why they wished to transition—it was like “listening to them read from a Facebook manual”.

She defended Dr. Littman’s 2018 ROGD study, which generated an international backlash from “gender-affirming” clinicians and trans activists, as well as pressure for the journal to issue a “correction” which in fact left the Littman hypothesis unchanged.

Dr. Haahr’s gender clinic colleague, chief physician Astrid Højgaard dismissed the ROGD hypothesis and objected that right-wing groups were enthusiastic about the idea of trans social contagion.

But Dr Haahr said: “It is not my impression that Littman has done the research to appease the right wing or because she is transphobic, but because she thought the phenomenon should be studied.

“I think that if we can’t talk about this very large increase in the number of birth-assigned girls seeking to change their bodies during puberty, then it’s going to be a problem for all transgender people in the future.”