Just say no

Norway's doctors should be aware they have the right to refuse to go along with "medically irresponsible" gender treatments for minors

Think twice

Physicians must have the courage to defend minors from experimental “gender-affirming” interventions and insist on their own legal right to refuse to take part in “medically irresponsible treatment,” according to an editorial in the Journal of the Norwegian Medical Association.

Signed by a group of nine doctors, the September 1 editorial also argues that compulsory school material in Norway may present gender identity as a simple, safe and reversible choice, thereby contributing to the unprecedented spike in teenage girls referred for irreversible hormonal treatment.

“Given the uncertain long-term effects and serious risk of side effects, medical ‘gender-affirming’ treatment for minors must still be considered experimental. This justifies the need for a more restrictive practice and clearer guidelines,” the editorial says.

“In a situation where professional consensus is lacking and there are serious concerns about the benefit and safety of the treatment, it is crucial that we as doctors dare to take on the role of the patient’s medical defender.

“We must not forget the most important principle of the Hippocratic Oath: Primum non nocere—first and foremost, do no harm.

“This also means that, based on assessments of what is reasonable, we may have to refrain from certain treatments that patients or patient organisations request. In such situations, it may be relevant to remember that Section 4 of [Norway’s] Health Personnel Act gives doctors the right to refrain from participating in treatment that is considered medically irresponsible.”

Working variously as general practitioners, public health specialists and chief medical officers, the authors of the editorial note the rise in young people wanting hormonal intervention at first contact with a doctor, and they also stress the role of ideology and conflict in the public debate.

“We have long felt the need for a more nuanced medical debate on this issue, but it has taken time to gather courage,” they say.

“While patients’ experiences and feedback are undoubtedly valuable, we believe that doctors’ decisions must first and foremost be based on thorough medical and ethical assessments of the available evidence, where potential risks are carefully weighed against documented benefits before new treatment methods are implemented.

“Although gender incongruence is not currently classified as a mental disorder, experience and research show that many of these children and adolescents also struggle with mental health problems, and a major concern is the high incidence of psychiatric comorbidity.

“This is not always thoroughly assessed before irreversible treatment measures are implemented. In some cases, this can contribute to a deterioration in overall health, which several of us have encountered examples of.”

A physician’s predicament

Against a background of international pressure for primary care doctors to expand and “mainstream” hormonal treatments for teenagers and young adults, the September 1 editorial warns of the dilemmas and dangers in Norway where an activist-influenced 2020 gender-affirming treatment guideline remains in force.

This is despite calls for its revision by the independent Norwegian Healthcare Investigation Board (Ukom) and the medical directors of the country’s four health regions.

In its 2023 report, Ukom found that the Norwegian Directorate of Health’s 2020 guideline “may pose a patient safety risk.” Ukom had investigated following complaints from families about the practice of paediatric medical transition.

Shortly after the release of Ukom’s report, the head of the health directorate, Bjørn Guldvog, made conflicting statements about whether or not the guideline would be reviewed. He reportedly had begun talks with regional health authorities, the specialist gender clinic at Oslo University Hospital, and patient groups, among others.

Last week, a spokeswoman for the directorate told GCN that a review of the guideline was “likely to be carried out over the next year”.

She said guidelines were updated “at regular intervals” and Ukom’s advice was “something we read and include in the overall assessment” as part of a guideline update.

The directorate was “in dialogue with the regional health authorities about when their [treatment pathway] descriptions will be updated in accordance with changes in the treatment services”.

Asked whether the directorate agreed with Ukom’s warning that patients may suffer harm as a result of gender-affirming medical treatment recommended by the 2020 guidelines, the spokeswoman put the responsibility on the health service providing these hormonal treatments to minors.

“The Directorate of Health believes that young people with gender incongruence should receive treatment that is customised to the individual,” she said.

“It is therefore individual which treatment will be beneficial or harmful. The guidelines are indicative, and it is the executive health service that makes the individual assessments in relation to the patient’s needs.”

Ukom’s 2023 declaration that paediatric medical transition is “experimental” and lacks sufficient evidence has led some international commentators to assume, wrongly, that Norway’s health authorities are already among the European countries to have adopted more cautious treatment guidelines.

In their September 1 journal editorial, the doctors say: “While Finland, Sweden, and the United Kingdom have moved away from ‘gender-affirming’ treatment of minors and now prioritise mental health measures as the only treatment outside of a research context, this is still not the case in Norway.”¹

“It is concerning that Norwegian guidelines still do not clearly limit medical gender reassignment for minors. Particularly problematic is that the Norwegian Electronic Medical Handbook, used by most general practitioners, lists irreversible medical interventions without clearly communicating the weak evidence and significant safety concerns.

“At the same time, there is a lack of knowledge-based tools that support conservative treatment, including psychoeducational and therapeutic measures that can strengthen the patient’s emotional regulation, identity development, and social coping.”

The editorial warns that the lack of balanced guidance, based on evidence, is also a problem for Norway’s school health services, special education advisers and teachers.

“Schools are obliged to teach about gender identity and sexuality from an early age, but many teachers lack the necessary medical and psychological insight into the topic of gender incongruence. This carries the risk of presenting gender as a simple choice with no consequences and treating incongruence as safe, easy and reversible,” the doctors say.

They note Ukom’s recognition of the dramatic increase in gender clinic referrals, especially for teenage girls who identify as boys, in many cases with no previous history of gender dysphoria.

“Although the causes are complex, there is reason to ask to what extent school communication and media influence—without a solid professional framework— contribute to this development.”

The editorial also cites side effects of gender-affirming hormonal and surgical interventions such as infertility, irreversible damage to reproductive organs, osteoporosis, thickening of the blood and other cardiovascular risks, infections, fistula formation, necrosis, chronic pain and urinary problems.

“In addition to a problematic balance between risk and [scant] evidence of positive long-term effects, it is worrying that many patients later regret undergoing medical gender reassignment,” the editorial says.

“This is believed to be under-reported in existing literature due to high dropout rates in follow-up studies. The risk of regret is thought to be particularly high among minors, as young people are still developing their identity and sexuality and thus naturally experience uncertainty.

“Many adolescents with gender incongruence are not mature enough to fully assess the consequences of irreversible treatments, which complicates a responsible informed consent process. Patients who undergo medical gender reassignment at a young age may experience challenges related to intimacy and family formation later in life.

“Referrals to specialist health services are increasing—even in cases where patients request measures that have no professional basis. In some cases, the threshold for initiating irreversible and risky procedures seems too low, which may be partly due to weak guidelines.

“The Norwegian Directorate of Health’s guidelines from 2020 emphasise patient participation and decentralised health care but are unclear when it comes to limiting medical treatment in favour of mental health care as the first choice. This is despite the fact that in 2023, the Norwegian Healthcare Investigation Board (Ukom) clearly recommended stricter practices and restrictions on hormone-modulating treatment in children and adolescents.

“General practitioners and other health professionals need tools that establish that responsible treatment primarily involves psychoeducation, psychotherapy, and social support—for the benefit of the patient and for a professionally safe health service.”

1. The restrictions in these jurisdictions are not absolute. In the UK, for example, cross-sex hormones are still available for minors outside research.