Around the World in Gender Medicine

Political and scientific debate is driving change

The debate over pediatric gender medicine is both international and local. Medical regulation takes place at the federal, state or provincial level where it is often highly dependent on local politics. In the United States, this has led to a confusing and contradictory patchwork of state and federal laws. It is international because medicine is an international enterprise and developments in a small nation can have ripple effects across the world. Pediatric medical transition began in the Netherlands and quickly spread throughout the developed world. The pullback began in Finland and is slowly spreading. This article will examine the current state of the gender debate in various countries to get a better sense of how it may unfold.

Equaldex is a crowd-sourced project that collects data on the state of LGBTQ+ rights. They have created a map that shows the current rules on access to gender-affirming medicine around the world.

Only a few countries totally ban gender reassignment. In 2023, Russia passed a federal law banning all forms of gender reassignment. Afghanistan, Oman, Saudi Arabia, Iraq, Egypt, Chad, Uganda, Somalia and Iraq also have total bans.

China allows gender reassignment surgery under very tight restrictions. It is only available to unmarried adults with a medical diagnosis of gender dysphoria who have persisted in demanding surgery for at least five years. Parental consent is required regardless of age. South Korea has similarly tight restrictions. Patients must be over 20, unmarried, have no underage children, obtain parental consent and, in the case of MtF transitions, obtain an exemption from military service. In much of Africa, medical transition is not banned but the health care system does not provide it and very few people can afford to travel abroad for treatment.

Iran is a special case. Homosexual relations are banned and may be punished by death. However, gender reassignment is legal, albeit restricted, and Iran is a world-leading center for gender reassignment surgery. This has led to the disturbing situation of gays being coerced into undergoing a vaginoplasty in order to avoid the death penalty.

Some parts of the Equaldex map are not entirely accurate. For example, it lists Thailand as a country where gender affirming procedures are legal. Thailand is a major centre for gender reassignment surgery, which attracts patients from around the world. It is notorious as the country where Susie Green of Mermaids Gender took her 16-year-old son for a vaginoplasty. However, since then Thailand has tightened its laws. Surgery is no longer permitted on patients under the age of 18 and patients aged 18 to 20 require parental consent. The map shows Brazil as a country where treatment is legal but the information page states that surgery is limited to those above 18 and hormonal treatment to those above 16.

An article entitled Evolving national guidelines for the treatment of children and adolescents with gender dysphoria: International perspectives by Kasia Kozlowska and an international group of 22 researchers and clinicians provides another perspective. It examines treatment guidelines in 13 countries that have adopted the Dutch protocol and finds that they fall on a continuum. At one end are rights-based approaches that emphasize patient autonomy and the fulfillment of expressed needs and, at the other, are evidence-based approaches that are based on systematic reviews and prioritize patient safety. The rights-based model relies on the Standards of Care of the World Professional Association for Transgender Health and is commonly known as the gender-affirming model.

Ground Zero in the Netherlands

Medical transition for children and adolescents began at the gender clinic at the University Medical Centre in Amsterdam. The original Dutch Protocol, which was developed in the late 1990s, consisted of puberty blockers at the onset of puberty (Tanner Stage 2 or age 12), cross-sex hormones at age 16 and surgery after age 18. The protocol was limited to patients with childhood gender dysphoria that worsened with the onset of puberty. Patients had to be free of co morbid psychiatric conditions and the parents had to be supportive. In the original research studies, psychotherapy was provided along with hormones and surgery. The first of two studies on the protocol was published in 2011, and the use of puberty blockers and cross-sex hormones on young people spread rapidly to other countries.

While the initial Dutch Protocol had strict eligibility requirements, these were not always followed in practice. In 2018 a revised protocol was issued which eliminated the requirement for childhood gender dysphoria, allowed non-binary medical transitions and reduced the role of psychological assessment. The minimum age for cross-sex hormones was reduced from 16 to 15 and for mastectomy from 18 to 16.

In 2023, a debate over the Dutch Protocol began in medical and legal journals and the media. A legal assessment of the Dutch Protocol concluded that it did not meet the requirements to be recognized as a standard of care. In 2024, the Dutch House of Representatives passed two motions calling for a review of pediatric gender medicine. In February 2025, a committee of the Health Council was set up to conduct the review. A report is expected sometime in late 2025 or 2026.

In September, 2025, the lower house of the Dutch Parliament approved a conversion therapy law that includes gender identity. The bill is being considered by the Senate. There is no information available in English on how the bill might affect exploratory psychotherapy for gender dysphoria.

Changing Course in Finland

Finland is another small country that has had an outsize influence on the debate on pediatric gender medicine. It adopted the Dutch Protocol in 2011 and opened two pediatric gender clinics. After a number of years, clinicians noticed that the patient population was growing rapidly and differed from the patients in the Dutch study. While the Dutch Protocol was intended for cases of gender dysphoria which commenced in childhood and became worse during puberty, the patients at the Finnish clinics were predominantly adolescent girls who first experienced gender dysphoria after puberty. They also noted that mental health outcomes did not seem to improve with cross-sex hormones. Psychiatrists at the two clinics requested that the Council for Choices in Health Care conduct a review. The council commissioned the first systematic review of hormones and puberty blockers for gender dysphoria, which found the supporting evidence weak, and issued new treatment guidelines recommending a much more cautious approach. Psycho social interventions are the first line of treatment and puberty blockers and cross-sex hormones, while still available, are used only in severe cases.

Sweden, Denmark and Norway

Sweden was the next country to change course. The National Board of Health had issued guidelines for the treatment of gender dysphoria in children based on the Dutch Protocol in 2015. The impetus for change came from lobbying by concerned parents and clinicians and the television documentary the Trans Train. As a result, the government ordered a review. A systematic review found only low certainty evidence supporting gender affirming care and the National Board of Health issued new guidelines which prioritized psycho social interventions and limited puberty blockers and cross-sex hormones to a research setting.

Clinicians in Denmark have followed developments in Finland and Sweden and have quietly adopted a more cautious approach which prioritizes counselling.

In 2023, the Norwegian Health Care Investigation Board issued a report that recommended that puberty blockers, cross-sex hormones and surgery for minors be restricted to research settings. However, the Norwegian Health Directorate has not acted on this recommendation and a 2020 guideline which favours the affirmative model of care remains in place.

The American Patchwork Quilt

In the United States, the debate over pediatric gender medicine has split on partisan lines. Conversion therapy laws and bans on medical transition of minors have created a strange patchwork quilt of prohibitions. The HRC reports that as of July 2025, 40.1% of “trans youth” are living in the 27 states that have banned medical transition for minors. According to the Movement Advancement Project, 27 states have a total or partial restriction on the provision of “conversion therapy” to minors by licensed health care providers. The map shows how these laws overlap.

North Dakota, Utah, Arizona, North Carolina and New Hampshire have all adopted bans on medical transition and some form of conversion therapy law. In the case of Arizona, the medical ban is limited to surgery. A number of states have also adopted “sanctuary laws” which enable non-resident minors to obtain medical transition treatments which are not available in their home states.

The actual overlap is larger. Pressure from the federal government has resulted in hospital gender clinics closing, which will restrict the availability of medical transition in states with conversion therapy laws. In states without conversion therapy laws, internal policies of professional associations, universities and clinics may have the same effect. Major medical associations all support the affirmative care model and oppose treatment bans. However, the American Society of Plastic Surgeons has expressed some concern about the evidence base for gender surgery for adolescents.

The divisive debate is likely to continue. The Trump administration has talked about federal legislation to ban pediatric medical transition and, meanwhile, is using other means like investigations through the Federal Trade Commission, to restrict it. The United States Supreme Court will be hearing arguments on a constitutional challenge to a state conversion therapy law this October. Although the Supreme Court decision in Skrmetti ended challenges to state bans on pediatric gender medicine through the federal courts, there are still a number of challenges to the legislation based on state constitutions.

This leaves health care providers in a bind. They cannot satisfy their young patients’ desire for medical transition but they also cannot provide effective psychotherapy. The result will be that many gender dysphoric youth will be kept in a sort of holding pattern until they turn 18.

The United Kingdom

The Cass Review recommended a new model of care, which, like the Finnish and Swedish models, prioritized psychotherapy. It recommended that use of puberty blockers be limited to research settings and the use of cross-sex hormones only at age 16 or older and only after careful psychological assessment. The UK has avoided the partisan divide of the US. The Cass Review was commissioned by a Conservative government, but it was the result of years of non-partisan work by concerned parents, clinicians, de-transitioners and groups such as Transgender Trend. The Labour government has accepted most of the Cass Review recommendations.

However, there are still unresolved controversies. The National Health Service has commissioned a clinical trial on puberty blockers, which is awaiting ethical approval. The Clinical Advisory Network on Sex and Gender has argued that a puberty blocker trial is not ethical. The government has also pledged to introduce a ban on conversion therapy which covers gender identity. Unless this ban is very carefully drafted, it could make it difficult to implement the Cass Review recommendations on psychotherapy.

Welcome to Tranada

Canada has also avoided a partisan divide on gender issues because, until recently, every political party has been fully captured by gender ideology. The Canadian Parliament passed a restrictive conversion therapy law with all party consent. Every province currently allows prescriptions of puberty blockers and cross-sex hormones to minors. The WPATH standards of care have been generally accepted. Every medical association and medical school has expressed strong support for gender affirming care.

Only two provincial governments have questioned the ruling consensus. In Quebec, the report of the Comité de sages on gender identity raised some concerns about the state of pediatric gender medicine and called for more rigorous research. The government of Alberta has adopted legislation that restricts medical transition for minors. However, a judge has granted an injunction against the implementation of the legislation and the case is ongoing. If a court finds that the Alberta legislation violates the Canadian Charter of Rights and Freedoms, the Alberta premier has said that she will invoke the notwithstanding clause in the Charter, which allows a legislature to override a court decision. The override must be renewed every five years and it would probably not survive a change in government.

Change in Australia

Australia has been competing with Canada for the dubious distinction of being the last country to end the scandal of pediatric gender medicine. The Australian standards of care support the affirming approach and four of six states have adopted conversion therapy bans. However, there are some signs of change. The State of Queensland has issued a temporary ban on new prescriptions of puberty blockers and cross-sex hormones for minors while it conducts a practice review. The Australian government has announced its own review of practice guidelines, which is expected to report in 2026.

Germany

In Germany, medical transition of minors is legal and conversion therapy has been restricted. New medical guidelines on medical transition of minors are consensus based, rather than evidence-based, rely heavily on the WPATH guidelines, and favour the affirmative approach. However, an analysis by the Society of Evidence Based Gender Medicine notes that the new guidelines contain some moves toward more caution. A psychological assessment cannot be skipped and a differential diagnosis should be considered. The guidelines also acknowledge that gender non-contentedness is often temporary and peer influence may lead to temporary transgender identification. They recommend limiting medical interventions to cases where gender dysphoria is stable and persistent.

France

France currently follows the affirming care model, but there is intense debate both at the political and professional level. In 2022, the National Academy of Medicine issued a statement calling for caution in the medical transition of children and adolescents. In 2024, Senators from the centre-right Republican party prepared a report that was critical of pediatric gender medicine, and the Senate approved a bill to ban medical transition for minors. The Macron government opposes the bill and it is unlikely to pass in the National Assembly.

Support for the gender-affirming model in France remains strong. In November 2024, the French Society of Pediatric Endocrinology and Diabetology issued an expert consensus on endocrine management of transgender adolescents, which completely ignores the findings of the Cass Review, which was published a few months earlier, and strongly endorses the affirmative model.

The French National Authority for Health (La Haute Autorité de Santé, HAS) had prepared a draft treatment advice which recommended allowing 16- and 17-year olds access to hormones and surgeries was leaked to the press. The draft was withdrawn as a result of public concern. In July 2025, HAS issued recommendations for medical transition for adults which adopt a self-determination policy that does not require a medical diagnosis. Separate recommendations for patients under 18 will be issued in 2026.

Italy

Italy has also been moving to tighter regulation of pediatric gender medicine. The shift was initiated by the election of a right-wing government, but the government has sought the backing of the health care profession. In December 2024, the National Bioethics Committee issued a report which recommended that puberty blockers be provided only in the context of a research trial, after mental health interventions had failed. The government has now introduced a bill which provides that gender affirming medical treatment is to be provided to minors only in the context of a protocol to be established by the health ministry.

International Developments

The World Health Organization has stated that it would not be proceeding with treatment guidelines for children and adolescents with gender dysphoria because the evidence base was insufficient.

The European Society for Child and Adolescent Psychiatry has issued a statement on care for children and adolescents with gender dysphoria which questions the evidence base for the gender affirming model and calls for higher ethical and scientific standards.

The European Academy of Pediatrics has also issued a statement which discusses some of the ethical concerns with gender affirming treatments, particularly the impact of fertility.

Two Paths Forward

The debate on pediatric gender medicine follows both a political path and a professional and scientific path, although the two often intersect.

The political path depends heavily on the national or regional political culture. It is often unpredictable because gender medicine has not been a major issue in election campaigns. In much of the world, pediatric gender medicine has been framed as a human rights issue and linked with lesbian, gay and bisexual rights. This is slowly changing. Groups like LGB Alliance argue that pediatric gender medicine targets young gays and lesbians and puts them on hormones before their sexuality is fully developed. De-transitioners, many of whom are lesbian or gay, have taken a leading role in the call for reform. However, the main LGBTQ groups still support the gender affirming model and change has generally been initiated by conservative politicians.

Reforming pediatric gender medicine also requires support from the medical and mental health care professions. Governments can ban harmful treatments but they cannot legislate good treatment. Any political debate needs to be linked to a professional and scientific debate to achieve any progress. The scientific and professional debate is international. Research in one country can be applied around the world. Even when their influence was at its height, transgender activists were never able to suppress debate everywhere at once. Concern about the lack of evidence to support the gender-affirming model, and its obvious harms, is spreading around the world. The debate continues. National reviews in France, Australia and the Netherlands are expected in 2026. It is hard to predict which way the recommendations in each country will lean, but it is no longer possible to provide unquestioning support for the affirming model and retain scientific credibility.