Florida Governor Ron DeSantis and a bunch of GOP lawmakers have a weird new obsession that’s really catching on: citing recent restrictions on gender-affirming care in Europe to justify bans on gender-affirming care right here in the U.S. of A. 

Brandon Wolf, a spokesperson for Equality Florida, an LGBT rights advocacy group in the state, said that DeSantis and his allies have cited anti-trans policies in places such as England, Sweden, and Finland “every step of the way” as the basis for criminalizing doctors who provide gender-affirming treatments. 

Invoking these “more liberal democracies,” as DeSantis called them in an interview with Glenn Beck, serves as a rhetorical ploy to cloak the GOP’s crusade against trans people in the language of liberal progressivism. This well-worn tactic has been persuasive to moderate Republicans and even some independents and liberal-leaning centrists, and it could boost support for the life-threatening trans health care bans currently sweeping the U.S

But a deeper look at Europe shows a far more complicated picture than the one Republicans are painting. Unlike what’s happening here, England, Sweden, and Finland aren’t banning gender-affirming-care, though it is more difficult to access. And trans people in these countries say that European health care systems and politics more broadly may not be so “progressive” when it comes to trans issues. 

New Restrictions Mean Care Is Still Available–If Your Parents Can Afford It

A Seattle demonstrator on Transgender Day of Visibility expresses their displeasure with US trans health care bans. streetphotojournalism

First, a significant distinction: these Republicans never mention that the U.S. bans go much further than the European restrictions. Florida and other red states are criminalizing care. The European restrictions themselves vary slightly from place to place, but, broadly speaking, they tighten eligibility criteria for puberty blockers and hormones, and they require adolescents to enroll in research studies to receive the medication.

Additionally, because the guidelines pertain only to the national health systems in these countries, adolescents who don’t meet the criteria can still access gender-affirming care through private clinics. In the era of telehealth, this process is becoming easier, but it’s not cheap. Lupron, a commonly used puberty-blocking treatment for transgender adolescents, costs over $2,000 per dose.

A representative from GenderGP, an international online clinic that prescribes gender-affirming treatments, said in an email that they have seen an uptick in patients under 18 in England, Sweden, and Finland since these new restrictions were passed.

Elias Fjellander, the President of RFSL Ungdom, the Swedish Youth Federation for LGBTQIA rights, said that this situation is creating a two-tiered system where wealthier families can get gender-affirming care for their kids while less-affluent families can’t. “It becomes an issue of the size of your wallet regulating whether or not you can access necessary care,” Fjellander said.

Gatekeeping Health Care From Adults

Republicans also fail to mention that England, Sweden, and Finland had already built systems that made accessing gender-affirming care at any age extremely difficult. 

In the United States, adults can receive gender-affirming hormones through a process of informed consent, which does not require a mental health evaluation. However, adults in England, Sweden, and Finland must endure a rigorous gatekeeping process to access care through their national health systems. That process involves months or even years of consultations with psychiatrists and psychologists, who then determine whether to allow their patients to medically transition.

With the exception of Finland, which just changed its gender recognition laws earlier this year, even those who seek out hormones or other treatments on the private market must go through the medical gatekeeping process to get an official diagnosis that allows them to legally change their gender.

Danni Askini, executive director of Gender Justice League, who lived in Sweden for several years and who sought gender-affirming care while she was there, compared the evaluation process to “going to fucking Catholic confession.” 

She said medical providers asked her extremely intimate questions, such as requests for descriptions of her “first sexual fantasy” and questions about whether she’d ever fantasized about “having sex as a woman with a viagina.”

Proponents of these gatekeeping models, which were also common in the U.S. until around the start of the 2010s, say they’re necessary to ensure that people will not regret their transition.

But Jules Gill-Peterson, an associate professor of history at Johns Hopkins, said that clinicians in the 1960s developed the models in response to fears of blowback from colleagues at a time when medical transition was first becoming widely practiced.

Those early practitioners, she argued, weren’t actually worried if people would regret transition–they were mostly concerned about their professional reputation. They had “a waiting list out the wazoo of people who are ready and willing” to transition, she said, and the gatekeeping protocols helped weed out noncompliant patients who might embarrass doctors after transitioning by not being sufficiently gender-conforming and by not passing consistently as their gender in public.

The World Professional Association for Transgender Health (WPATH), the preeminent medical association of trans health care providers, does not recommend that sort of gatekeeping in its latest guidelines. 

The legal gender-change process in the UK and Sweden adds another round of gatekeeping through interviews. Katy Montgomerie, a UK LGBT rights advocate and popular YouTube commentator, described the line of questioning in her interview for a legal gender change as “invasive and horrible.” 

“I had to give a description of my genitals,” she told The Stranger.

Until this year, Finland required formal medical transition and interviews to legally change gender. In February, the Finnish Parliament passed a law to scrap those requirements, as well as the requirement to sterilize trans people over 18 who want to legally change their gender.

Amnesty International praised the reform, but it also said that the decision not to allow minors access to legal gender changes violated the UN Convention of Human Rights of the Child. Sweden also had a sterilization requirement, which courts struck down in 2013. 

“More Liberal Democracies Than We Are”

Facing a wave of anti-trans legislation in the U.S., demonstrators march through Seattle on Transgender Day of Visibility. streetphotojournalism

Though it might seem like the anti-trans movement only exists here in the US, England and Sweden are currently seeing a rise in organized transphobic movements, and there’s some evidence that those movements have had an impact on the decisions made by their health care systems to restrict gender-affirming care for adolescents.

Under Theresa May’s administration, the UK government planned to allow people to self-declare their gender identity nationwide. But the proposed self-declaration law, often referred to as self-ID, ultimately failed, thanks in part due to opposition from the UK’s gender-critical movement. 

Montgomerie says that the movement, “Carve[s] out an anti-trans position while framing it as a pro civil rights movement.” Specifically, they claim trans rights are harmful to cis women and cis gay and lesbian people.

Buoyed by high-profile figures such as JK Rowling, the movement has grown over the past several years. Montgomerie says it has also gotten more extreme since Rowling joined the cause in 2020: “Before JK Rowling came out, there was more room for gender-criticals to have moderate positions. And I think that as they've [gotten] bolder, they've got more political power, the government has moved farther right.”

A sign of the movement’s growing extremism came last year when Helen Joyce, a former editor at The Economist and a high-profile gender-critical figure, made comments eerily similar to those of Michael Knowles’s call for the eradication of “transgenderism” at the Conservative Political Action Coalition conference (CPAC) in March. 

Joyce said that the goal of the gender-critical movement should be to reduce the number of people who transition because those who do are “damaged” and “a huge problem to a sane world.”

The UK government has also moved away from trans rights since May left office. Both Prime Minister Rishi Sunak and his predecessor, Liz Truss, oppose self-ID. And while the country’s independent Cass Review on gender identity services did not make definitive recommendations on the use of gender-affirming treatments, Sunak and Truss campaigned on a promise to “review” the practice of prescribing blockers.

Reuters reported last year that “[England’s National Health Service’s] proposed new treatment guidelines were altered after they were reviewed earlier this year by a Conservative government wary of medical interventions for transgender adolescents.” NHS England did not respond to a request to comment for this story.

Meanwhile, Scotland’s government has been much friendlier to trans people. The Scottish parliament passed a self-ID law last year, which Sunak is attempting to block in court. Scotland’s NHS also took the lack of definitive recommendations in the Cass Review the other way and continued offering puberty blockers. A spokesperson for NHS Scotland said in an email that their policy is determined “solely on a clinical basis.”

Swedish LGBTQ youth advocate Fjellander said the gender-critical movement is also on the rise in his country. “It's the queer movement against the women's rights organizations who have now suddenly become gender-critical,” he said. 

Angela Mitrovich, a trans woman living in Stockholm, said she spent three years working in women’s aid and found it difficult to work in that space. “The woman in charge there bullied me and the trans guy who worked there before me,” she said.

Fjellander and Mitrovich both talked about the rise of right-wing movements in their countries, as well. The far-right nationalist Sweden Democrats party is part of an increasingly hostile climate for trans people in the country. The party is now the second-largest in Parliament, and the government coalition relies on its votes to stay in power.

Fjellander said that local politicians from the Sweden Democrats are trying to get drag queen story hours banned from libraries. Mitrovich said that “self-identifying Nazis” are protesting these events.

Fjellander also talked about the influence of a documentary that aired on Sveriges Television (SVT) called The Trans Train. The documentary focuses heavily on detransitioners and promotes the theory of “Rapid Onset Gender Dysphoria” (ROGD), an idea that suggests that teenagers are seeking medical transition due to social contagion rather than actual gender dysphoria.

The ROGD hypothesis is based on a study of parents largely recruited from anti-trans websites that promote pseudoscientific treatments for gender dysphoria, and the journal that published it says that it is not a clinically validated phenomenon or a diagnostic guideline. Several subsequent studies have discredited the theory.

A 2022 study published in JAMA Network Open examined the media coverage of trans issues in Sweden, including The Trans Train, and found that the coverage was associated with significantly reduced referrals to gender clinics. The authors suggest such coverage can jeopardize access to care.

Gender-critical activists also credit The Trans Train for influencing Sweden’s policies. Rose Kelleher, a blogger for Genspect, a gender-critical organization that opposes medical transition for anyone under 25, wrote, “Things began to change when the famous Trans Train documentary was aired in April 2019.” Genspect promotes the documentary on its website.

A spokesperson for the Swedish National Board of Health and Welfare, the agency responsible for Sweden’s new restrictions, said that SVT’s coverage of the issue had no impact on the board’s decision, and that those directly involved in the review process “made an active choice not to watch these TV-programs when the work was ongoing.”

Poking at the Evidence

Poke. streetphotojournalism

England, Sweden, and Finland’s new, restrictive policies have also provided another avenue for attacks on gender-affirming care: questioning the growing body of research showing that the care improves mental health outcomes for adolescents.

Dr. Jack Turban, assistant professor of child and adolescent psychiatry at the University of California - San Francisco, compiled 16 studies on these adolescent treatments in a piece for Psychology Today. In his article, Turban concluded that “taken together, the body of research indicates that these interventions result in favorable mental health outcomes.”

The American Medical Association, the American Academy of Pediatrics, the Endocrine Society, and the American Psychological Association have all concurred that these treatments are beneficial based on the available evidence.

However, Republicans looking to ban gender-affirming care for adolescents claim that these medical associations are all practicing medicine based on “wokeness” rather than evidence. And to support this claim, they’ve cited reviews from some of these European countries showing that the studies for gender-affirming care are “low quality” under something called the GRADE system.

Scientists use the GRADE method as a tool to evaluate systematic reviews; it rates evidence from “very high quality” to “very low quality.” Randomized controlled trials are presumed “high quality” evidence, and observational studies are rated as “low quality” evidence.

Researchers have said that conducting randomized controlled trials for gender-affirming treatments would be unethical because it would require denying potentially life-saving health care from the control group.

Dr. Dan Karasic, professor emeritus of Psychiatry at UC - San Francisco, said that opponents of gender-affirming care use the GRADE system to hold the evidence on this issue to “an impossible standard”.  

“The ‘low quality’ [rating] is just going to be how anything is assigned by GRADE. If you don’t have randomized controlled trials, your study is not going to have a high GRADE score,” said Karasic.

According to Karasic, prescribing treatments that have “low quality” evidence is common, especially in pediatrics. “We do all kinds of interventions, routinely where evidence is limited. So, it's not that we have randomized controlled trials for everything we do. And especially if you're working in mental health and you're working with minors, we're using interventions all the time that are not FDA-approved for minors.”

One of those treatments, Karasic says, is antidepressants. A systematic review performed by Cochrane, an international nonprofit research organization that has conducted thousands of systematic reviews, found that for children and adolescents “most antidepressants may be associated with a ‘small and unimportant’ reduction in depression symptoms.” And even this “small and unimportant” association was “low certainty” for some of these drugs.

And, like gender-affirming treatments, antidepressants come with serious risks. These risks include potential bone density loss, which is a commonly cited risk of puberty blockers, as well as suicidality. “Antidepressants have a black box warning in minors for an increase in suicidality, and yet we use them all the time because they help a lot of people,” Karasic said. 

Karasic also pointed to the fact that there are no studies showing that anything else works for gender dysphoria. “For those who do need it, there’s not an alternative treatment,” he said. 

Dr. Meredithe McNamara, assistant professor of Pediatrics at Yale, agrees that the term “low quality” can be misleading. “I would say that the problem is that ‘low quality’ evidence is a technical term that spiraled out from the GRADE method,” she said.

Last year, McNamara led a team of researchers who wrote a critical analysis of Florida’s new guidelines that cited “low quality” evidence to justify ending Medicaid coverage for gender-affirming care both for children and adults. McNamara’s analysis showed that a consistent application of this standard would force the state to deny coverage for mammograms, routine surgeries, and drugs that lower cholesterol. 

She argued that high-quality evidence is often not available to assess treatments on minors and for rare conditions, and so the lack of it isn’t a good reason to deny treatment. 

“You don’t need high-quality evidence to practice good care. You don’t need high-quality evidence to follow strong recommendations,” she said.

It All Comes Back to Florida

When the Florida Board of Medicine met last year to push through its ban on gender-affirming care for adolescents, they brought in a star witness to make the case that they were simply following Europe’s lead.

Dr. Riittakerttu Kaltiala, the head of Adolescent Psychiatry at Finland’s Tampere University Hospital, one of only two clinics in the country that treats dysphoria in adolescents, told the Board of Medicine that she believed gender-affirming hormonal treatment for adolescents should only be done in research studies. 

Kaltiala has promoted the ROGD hypothesis and lobbied Finland’s Council for Choices in Health Care (COHERE) to create its new restrictions. Dr. Patrick Hunter, a DeSantis appointee to the Florida Board of Medicine, said in an expert declaration that he has lectured with Kaltiala, and that she was “instrumental in recently changing Finland’s national transgender practice guidelines.”

Kehrääjä, a Finnish LGBTQ publication, reported that patients under the age of 16 at Dr. Kaltiala's clinic were subjected to invasive lines of questioning–including being asked to describe how they masturbate–as part of the process for evaluating access to gender-affirming care.

In a statement signed by Kaltiala, Tampere University Hospital said the specific incidents described in the article “bend the truth,” but they confirmed that inquiring about masturbation is part of the diagnostic process for those under 16.     

Dr. Olivia Danforth, a family physician in Albany, Oregon, who specializes in gender-affirming care for adolescents, described the practice of inquiring about masturbation in this fashion as “abusive”.

“Requiring this disclosure in the course of evaluation is abusive because sexual history taking should be done in a consensual and contextually indicated fashion. There is no meaningful evidence that we should make different medical choices based on that. When it’s built into a care pathway, you’re telling a teenager ‘give me this information so I can decide if you should have the puberty you want,’” said Danforth.

In an email to The Stranger, Kaltiala said that the clinic asks about masturbation because sexual development is “an important facet of adolescent development,” and she added that “in assessing adolescents’ health care needs, different facets of adolescent development are elicited.”

She also defended her stance on ROGD: “I have seen so many young people who experience gender dysphoria or present with transgender identity in adolescence after no sign of any distress related to gender or any sign of gender nonconformity in childhood,” she said. 

Savu, who has been a patient of Kaltiala’s clinic, and who asked to be identified by a pseudonym due to safety concerns, said that getting a diagnosis of gender dysphoria from the clinic took over two years, and that the clinic’s process included a number of roadblocks to accessing treatment.

After going through this process for over a year, at which point they had turned 18, Savu resorted to self-administering gender-affirming hormone therapy. They said that after revealing this information to a nurse, the clinic threatened to end their diagnostic process and to kick them out of the program if they did not stop using the hormones. “That was my first clearly negative experience with [the] clinic essentially blackmailing me to stop taking HRT,” they said. 

Kaltiala did not address the clinic’s threat to remove Savu from the program for initiating hormones on their own, but she said she was “sorry they are dissatisfied.” She suggested a number of reasons for why the process might have taken longer than usual, and added that “people’s accounts of events may sometimes be colored by their feelings.”

In spite of her testimony arguing for restrictions before the Florida Board of Medicine last year, in an email Kaltiala distanced herself from American politicians seeking to ban gender-affirming treatments, noting that those treatments remain available for adolescents in her country on a “case by case” basis. Florida policymakers considered allowing an exception for adolescents to get gender-affirming treatments through clinical trials, as Kaltiala suggested in her testimony, but ultimately they banned those, too.

National right-wing news outlets and commentators increasingly cite Kaltiala’s views, and with DeSantis preparing to launch a presidential campaign, it’s likely we will see more calls for federal policies to restrict gender-affirming care for adolescents, using England, Sweden, and Finland as a justification.

As Equality Florida press secretary Brandon Wolf ominously warned, “The entire country should be on notice that Ron DeSantis wants to be president in the United States and everything–every headline you're reading about Florida–is coming your way if he is successful.”