“The United States is the most permissive country when it comes to the legal and medical gender transition of children,” according to a 12-country policy review by medical advocacy group Do No Harm. The group compared “different legal requirements for gender change-related treatments and actions” among the U.S. and the 11 countries of Northern and Western Europe. These countries — Belgium, Denmark, Iceland, Ireland, Finland, France, Luxembourg, Netherlands, Norway, Sweden, and the United Kingdom — “share the United States’ broad support for transgenderism” yet “reject the gender-affirming care model for children.”
Do No Harm explained that America has adopted a “gender affirmation” policy for children, which “assumes that gender incongruence can manifest as early as age four and that questioning a minor’s gender self-definition is harmful and unethical. The American Academy of Pediatrics has embraced an affirm-only/affirm-early policy since 2018, and most states abide by its guidance despite withering medical and scientific criticism.” By contrast, some European countries “have explicitly abandoned” the gender-affirming care model and “now discourage automatic deference to a child’s self-declaration on the grounds that the risks outweigh the benefits.” They also recommend “months-long psychotherapy sessions to address co-occurring mental health problems.”
The report proceeded with a country-by-country comparison of requirements for the medical and legal gender transition of children.
American restrictions on puberty blockers vary by state, but “the most permissive states do not impose restrictions,” and blockers have been prescribed “as early as age eight.” Oregonians “are legally entitled” to blockers “from age 15,” with Medicaid assistance and without parental consent. In Iceland, there is “no minimum age” except as a “matter of clinical judgment.” The U.K. permits blockers “from the earliest stages of puberty,” while Belgium, France, and Norway permit blockers from Tanner Stage II, or “once physiological signs of puberty manifest.” Denmark, Netherlands, and Sweden allow puberty blockers “from age 12.” Finland allows them “about age 13.” Ireland allows them “under 16 years old.” In tiny Luxembourg, “no official guidance exists,” but “in practice, adolescents almost always receive blockers in a neighboring country.”
Restrictions on prescribing cross-sex hormones (estrogen and testosterone) to minors also vary state by state across the U.S., but “the practice has been documented with parental consent in children under the age of 13.” In Oregon, minors may “access cross-sex hormones from age 15 without consent and with Medicaid assistance.” France has “no age restrictions” on cross-sex hormones, but “clinicians generally will not administer them before Tanner Stage II.” Again, Luxembourg has “no official guidance,” but “Patients almost always receive hormones in a neighboring Country.” In every other European country studied, cross-sex hormones were available “from age 16,” although the U.K. requires that “individuals must have been receiving puberty blockers for at least one year.”
Do No Harm provided few specifics regarding the status of parental consent for these chemical gender transition procedures. They do say that, besides Oregon, “in most states, puberty blockers cannot be administered before age 18 without parental consent,” but they provide no insight on cross-sex hormones. However, California passed a bill in September effectively removing any parental consent requirement.
By contrast, children may not access gender transition chemical treatments until age 16 or 18 in nearly every country. Denmark is the most permissive, allowing children without parental consent to access puberty blockers at 15. In the U.K., “instances of children under 16 receiving blockers without consent are reportedly rare,” although such consent is not required. To access cross-sex hormones without consent in either country, children must be 16. In Iceland, Ireland, Netherlands, and Norway, children must be 16 to access either puberty blockers or cross-sex hormones, although Norway raises the age for cross-sex hormones to 18 “if the treatment is considered irreversible.” Sweden also allows cross-sex hormones without consent at 16, “so long as the individual is deemed sufficiently mature,” while it bars puberty blockers without consent until age 18. In Belgium, Finland, and France, neither treatment is available without parental consent until a person turns 18.
The report also compared the number of youth gender clinics in the various countries. The U.S. led by far, with “more than 60 pediatric gender clinics and 300 clinics” that “provide hormonal interventions to minors.” France also has many locations because “care is decentralized,” and “any doctor can prescribe treatment for medical transition.”
But after that the number quickly dwindles. Sweden administers all gender transition procedures through four hospitals, of which three provide surgery. Denmark administers gender transition hormones at only three locations. There are only two hospitals or clinics providing medical gender transitions in Belgium, Finland, and soon the U.K., which currently has one. Iceland, Ireland, Luxembourg, Netherlands, and Norway have one gender transition facility apiece. Granted, the United States is far larger than many of these countries. But the U.S. has a population 2.5 times larger than all the countries except France, while it has 20 times as many clinics providing hormonal interventions to minors.
Do No Harm also compared the minimum age at which countries allow persons to legally change their gender in civil registries. In the U.S., “there is no minimum age” for federal documentation, such as passports or Social Security cards, but such changes require the consent of both parents. There is more variation in state documentation, such as ID cards and birth certificates, but at least seven states “permit minors to change their birth certificate gender markers with parental consent.”
Three European countries, Iceland, Luxembourg, and the U.K., have policies similar to the U.S. federal government in that there is no age limit, but children under the age of 18 need parental consent to change legally recognized gender. In Norway, gender markers can be changed, with parental permission, from age six, and from age 16 without parental permission. Netherlands also allows 16-year-olds to legally change their gender without parental permission. In Belgium and Ireland, 16-year-olds may change their legal gender identity with parental consent, and 18-year-olds may change it without parental consent. Denmark, Finland, France, and Sweden do not allow minors under the age of 18 to legally change their gender identity.
The U.S. also exceeds most European countries in legally recognizing genders other than male or female. Federal “passports offer an X gender option,” and a sizable number of states allow a gender marker of “X” on identification documents (22 states plus D.C. on driver’s licenses, and 16 states plus D.C. on birth certificates). Only Iceland permits gender variation, allowing “third gender and/or nonbinary designations” on official documents. Denmark and Ireland allow a third gender option on IDs and passports respectively, but their “civil registry is binary.” In the Netherlands, a person may only obtain a gender neutral designation through a court. In the other seven countries, Belgium, Finland, France, Luxembourg, Norway, Sweden, and the U.K., “male and female are the only recognized genders.”
“The United States is the most permissive country when it comes to the legal and medical gender transition of children,” concluded the review. “Only France comes close, yet unlike the U.S., France’s medical authorities have recognized the uncertainties involved in transgender medical care for children and have urged ‘great caution’ in its use.”
“Given the growing body of evidence and the European consensus, which is grounded in medical science and common sense,” pleaded Do No Harm, “the United States should reconsider the gender-affirming care model to protect the youngest and most vulnerable patients.”