Transgender Health Care in Europe

Sweden is a Nordic country in Europe, part of the European Union. The country has a surface of 450 295 square kilometers, a total population of 10,4 million and a low population density. Sweden is a constitutional monarchy and a parliamentary democracy. It is a unitary state, but divided into 21 counties, which have the responsibility for health care and local traffic. Sweden maintains a Nordic social welfare system that provides universal health care for all citizens.

Given the long distances across the country there are six units, where health care for transgender people is offered. The National Board of Health and Welfare has last year taken the initiative to reorganize the transgender health care, which is an ongoing process. We founded the Swedish Professional Association for Transgender Health (SPATH) in 2007, with the goal to provide equal health care for transgender people throughout the country. The board of the Association organizes an annual conference for education and exchange of experience.

The Gender Equality Act regulates the legal aspects of health care for transgender individuals in Sweden.

The country has separate standards of care for children and adolescents, than for adults. The National Board of Health and Welfare has decided to update both, and has worked on the guidelines for children and adolescents since last autumn

This key note lecture will address contemporary state of transgender health care in Croatia. The specific cultural background will be discussed and possible improvements will be given.

Within the health care system in Republic of Croatia there is no systemic care under specific gender clinic for transgender people. Hormonal treatment is partially covered by the health care insurance, and gender affirmation surgeries are not covered by the health care insurance at all. Up till now there is only so-called “Virtual national team for transgender health care” consisting of a few enthusiastic interdisciplinary professionals. Some of them are working in different clinical hospitals, mostly in capital city- Zagreb, and some of them are working in the private sector.

In 2008 Croatian Ministry of Health has adopted the first “Bylaw about appropriate collection of medical documentation, determination of conditions and presumptions for sex change,” that allowed only for those trans people with complete sex affirmation surgery done to change gender mark in personal documents. Due to the efforts of professionals and LGBT non-governmental organizations, the Croatian Parliament has adopted on the behalf of Ministry of Public Administration adopted “The law of national registers” in 2013, which among other, defines the change of personal name and surname and change of gender designation in personal documents. On the 27^th of March 2014 Croatian Ministry of Health has adopted the “Bylaw about appropriate collection of medical documentation, determination of conditions and presumptions for sex change and/or life in other gender identity.” For the first time no surgical intervention for transgender individuals was needed as a condition for the change of gender mark in personal documents.

Apart from the new legal acts that regulate “life in lived gender identity” and “presumptions for sex affirmation”, in the field of medical and mental health care there are some insurmountable problems related to uncovered costs of gender affirmation process, lack of educated professionals and sensibility by the same legal system to ensure for each transgender person the time-appropriate treatment and legal protection. Current COVID- 19 pandemic represents huge obstacle as most of the hospitals are oriented on providing care for people with urgent medical conditions and COVID- 19 patients.

It would be in both the professionals’ and transgender people best interest if professional societies and chambers would implement, in their existing professional guidelines and ethical codes, specific paragraphs about comprehensive care of transgender people according to the Standards of care with respect to their human rights. That will allow for the transgender health care to be based on the up-to-date scientific knowledge and best practice recommendations, as to avoid the slightest possibility of prejudicially coloured belief system coming from the side of professional authority to interfere with practice. Minding the cultural background, the specific mark of harmfulness of so- called reparative therapy practices should be included. New round of discussion between professionals, transgender NGO’s, stakeholders and governmental representatives should be made in order to remove existing barriers of complete and affirmative transgender health care in Croatia.

In Denmark there has been a dramatic change of laws and guidelines regarding assessment and treatment of gender incongruence since 2014.

Before 2014 changing of legal gender required a psychiatric diagnosis of “transsexualism”. Only one clinic was entitled to put the diagnosis which was at the Sexological Clinic in Copenhagen that part of the psychiatric system in accordance with the belief that “transsexualism” was a psychiatric disorder. After assessment which averagely took 5.9 and 8.1 years for transmen and -women the Ministry of Internal Affairs had to be applied for permission to castrate the patient before legal gender change was allowed. Married transgender persons must divorce as same sex marriages was not allowed (although they could opt for a registered partnership after 1989). In 2014 a new law enabled people to change legal sex by an online application without having to be “diagnosed” and no questions asked.

In January 1, 2017 after massive pressure from trans organizations and Amnesty and other NGO´s, the diagnosis of ”Transsexualism” (DF 640) was removed from the psychiatric list of diagnoses by law from the Danish Parliament and the diagnosis was replaced by a contact code DZ768e1.  “Contact due to gender incongruence” – which emphasizes that there is neither a morbidity nor a sexual problem.

In October 2^nd 2017 the monopoly was abolished, and a new Center for Gender Identity was created in Aalborg as a separate unit at the somatic University Hospital in Aalborg. This was a strong marker of “de-psychiatrization” og transgender individuals.

All persons admitted to a CGI must be referred by a doctor. Treatment is for free except medication which only is partly reimbursed.

Each of the now three CGIs has a multidisciplinary team (MDT) consisting of gynecologists or endocrinologists, psychologists, psychiatrists, nurses and plastic surgeons. The team must agree on major steps in the transition. A somatic medical doctor is appointed as team leader for each patient ensuring a smooth path through the process and informed consent. Gender assigned males may have gamete cryopreservation to ensure a possibility for future (free) public fertility treatment. Facial hair removal and logopedic intervention are offered as well.

Treatment is individualized. At the CGI in Aalborg it is thus possible to removal of gonads without constructive surgery and mastectomy is a possibility without hormonal treatment for non-binary persons. Supportive consultations by psychologist / psychiatrist is offered but is not compulsory.

In my presentation I will give examples of a typical patient course, how the MDT works how the development in referrals has exploded since 2017. Finally I will describe the cooperation with relevant NGO organizations in development of a non-pathologizing approach at Center for Gender Identity at Aalborg University.

Introduction: A proper treatment of gender dysphoria requires multidisciplinary approach. There is a necessity for progress of transgender health-care in hungary, since prevalence has been increasing significantly. Our aim was to present the results and trends in our institution in Hungary.

Materials and methods:  From May 2014 until June 2021, totally 173 patients with gender dysphoria requested hormonal treatment in our institution. Among them  28 patient  aged 23 to 64  years (mean age:  32), underwent gender affirmative  genital surgery and 23 patient (aged 18 to 41 years, mean age: 28 years)  underwent gender affirmative top surgery. Preoperatively, complete psychiatric and psychological assessment was done, followed by proper endocrinological evaluation and treatment, according to WPATH Standards of Care. One-stage female to male metoidioplasty was performed in 6 transgenders, and included transvaginal hysterectomy, vaginectomy (colpocleisis), metoidioplasty with urethral lengthening, scrotoplasty and placement of testicular implants. Buccal mucosa graft combined with labia minora flap was used for urethral reconstruction in all cases. Penile inversion vaginoplasty, with clitoroplasty and introitoplasty was performed in 22 male to female transgenders and rectosigmoid colon vaginoplasty with intriotoplasty was performed in one case. Regarding top surgery ,4 breast augmentation and 19 subcutan mastectomy and chest reconstruction were performed.

Results: Follow-up period ranged from 2 to 85 months (mean 52 months). Mean postoperative hospital stay was 3 days (2-5 days) in connection with genital surgery, and one day (1-2 days) in connection with top surgery. Good postoperative outcome is achieved in all cases. In metoidioplasty group, voiding in standing position and preserved sensation of the neophallus is achieved in all patients. In male to female transgenders, good depth of the neovagina and preserved sensitivity of the clitoris are achieved in all cases. Complications were two minor costmetic genital revision, one urethral stricture in vaginoplasty cases,  two fistula in metoidioplasty cases,  and  3 haematoma , and one partial necrosis of nipple, and one cosmetic revision in mastectomy patients. All patients reported satisfaction with the outcome and improved psychological conditions. They have all remained under continuous multidisciplinary follow-up.

Conclusion: Trends of gender affirming surgeries in Hungary is increasing. Successful treatment of gender dysphoria requires multidisciplinary approach of experienced team.

Keywords: gender dysphoria,  gender affirmation surgery, vaginoplasty, metoidioplasty, top surgery, hormonal therapy.