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Conditions for changing legal gender
Pursuant to
applicable administrative practice, castration is required for changing legal
gender in
Norway. The expert group deems the current practice to be contrary to
fundamental
human rights.
The expert
group recommends that the right to change legal gender must apply without
conditions
being stipulated for specific forms of medical assistance. The expert group
recommends
that a person's desire to change legal gender must be separated from the
medical
treatment the person in question may wish to undergo.
The expert
group recommends that people must be able to change legal gender in Norway
without the
requirement of castration or other form or sterilisation.
When
discussing the conditions that should apply for changing legal gender, the
expert
group has
used three different models as a basis: The diagnosis model, which requires
that
people who
want to change legal gender are given a specific diagnosis, the assessment
model,
which requires that there is a professional psychological/medical assessment of
the
individual's
desire and decision and finally, the declaration model, which is based on
people
who
experience a lack of conformity between their own gender identity and
registered legal
gender,
being able themselves to request a change of legal gender.
The expert
group recommends that a personal declaration to the national registry
authorities
should be adequate for changing legal gender.
To ensure
that the change of legal gender takes place through an informed decision, the
expert
group recommends that the person who requests the change of legal gender should
receive an
information letter stating the consequences of the change when the first
request
to the
national registry authorities is made. To confirm that the decision is
definite, the
applicant
must return a reply form enclosed with the information letter.
In Denmark,
the applicant must have completed a "period of reflection" before
legal gender
can be
changed. The arrangement entails that the person who requests a change of legal
gender
must, after a period of six months, confirm the request before the change is
made in
the
national registry. With regard to the question of whether an equivalent period
of
reflection
should be introduced in Norway, the expert group has divided into a majority
and
two
minorities.
The
majority recommends that no requirements should be set for an imposed period of
reflection
for changing legal gender.
The
minority recommends that the declaration model is combined with a requirement
for a
time-specified
period of reflection. There are two alternative proposals for the period of
reflection
which are of one month and six months in duration.
Based on
current practice, there is no explicit provision regarding the age limit for
changing
legal
gender. However, the present requirement of castration has meant that no one
under
the age of
18 has changed legal gender.
The expert
group recommends that the age limit for the right to request a change of legal
gender
based on personal declaration should be 18 years.
In
addition, the expert group recommends that guardians be granted the right to
submit a
declaration
of change of legal gender for children upon approval from the County Governor.
The child
should be heard. If the child has turned 12 years of age, it is a requirement
for
approval
that the child has given consent.
Adolescents
between 16 and 18 years of age must themselves be able to submit a
declaration
for change of legal gender. The child's guardians must be informed, unless
there
are special
grounds for not doing so. If one or both guardians oppose the change of legal
gender or
are not informed, there must be approval from the County Governor.
The expert
group recommends that all those who are registered as residents in the Kingdom
of Norway
and who intend to reside here permanently, shall have the right to apply for a
change of
legal gender. It is further recommended that Norway acknowledges the legal gender
a person has had stipulated by a competent authority abroad in accordance with
the
laws of the
country in question.
The expert
group recommends that the conditions for changing legal gender must be
regulated
by law.
The expert
group recommends that the issue of introducing a third gender category be
examined in
more detail.
Medical
assistance to people who experience gender dysphoria
Norway's
human rights obligations, health legislation and general principles for
organising
health care
services provide the framework for the expert group's proposal for the
formulation
of a future health service option to people who experience gender dysphoria.
The review
of the present health services offered shows that many receive the medical
assistance
they request. However, it has also become clear to the expert group that there
are a
number of deficiencies and challenges in the services that are presently
offered. This
means that
many who are entitled to medical assistance relating to gender dysphoria do not
receive the
medical assistance they need and want.
The expert
group recommends that a greater number than those who are currently offered
treatment
in the health service are offered treatment and follow-up in connection with
distress
and discomfort relating to gender incongruence.
Increased
expertise in all parts of the health services
In the view
of the expert group, there is a major need for increased expertise in all parts
of
the health
services to ensure that people who experience gender dysphoria are offered
adequate
professional medical assistance and are met by health personnel who show them
understanding
and respect.
The expert
group is of the view that measures must be introduced to build up the necessary
expertise
for assessing, diagnosing and treating patients with gender dysphoria in all
parts of
the health
services. In the view of the expert group, the regional health trusts must
initiate
measures
for, among other things, identifying areas in which there is presently
inadequate
expertise.
The expert
group's recommendations to offer medical assistance to more groups who
experience
gender dysphoria than what is presently the case and the goal that the correct
level of
medical assistance is provided require that routines and guidelines are
prepared for
necessary
diagnosis and treatment in the regions.
The expert
group recommends that the regional health trusts commence necessary
measures
for ensuing there is sufficient expertise for being able to provide adequate
medical
assistance
for gender dysphoria.
Services
offered by the municipal health service
Based on
all available information, the number of people who require medical assistance
for
gender
dysphoria is and will remain at such a low level in Norway that it is not
realistic that
patients
will be able to receive specialist expertise in the municipal health service.
However,
health
personnel must still have sufficient knowledge and information in order for patients
to be met
with understanding and for correct measures to be able to be initiated. Many
patients
can have their needs covered by the municipal health service through, for
example,
the regular
GP, psychologist and health centre and school health service.
The expert
group recommends that regular GPs and other health personnel in the municipal
health
service are assigned a clearer role in the medical assistance offered to people
who
experience
gender dysphoria.
In the view
of the expert group, the primary monitoring of pre-pubescent children who
differ
from the
outside world's gender expectations should be locally based.
The expert
group recommends that the municipalities offer advice and guidance to parents,
day-care
centre, school and others when a child differs from the outside world's gender
expectations.
Services
offered by the specialist health service
In the
recommendations that apply to services offered to adults by the specialist
health
service,
the expert group has divided into a majority and two minorities.
The
majority of the expert group is of the opinion that there is a need for
significant
decentralisation
of the medical services offered to people who experience gender dysphoria
in order to
service the groups that are not currently offered medical assistance.
The
majority recommends that each regional health trust must ensure that there is
available
endocrinological
treatment, surgery (with the exception of genital surgery) and other
necessary
medical assistance for adults who experience gender dysphoria. If the needs of
the patient
can only be met by highly-specialised expertise, the patient shall be referred
to
the
national treatment unit for transsexualism at the Oslo University Hospital
(NBTS, OUS).
The
majority recommends that the national treatment unit be responsible for
offering
highly-specialised
medical assistance at third-line level which can include diagnosis and subsequent
hormonal and/or surgical treatment. In addition, the expert group recommends
that the
national treatment service offers assessments of complicated endocrinological
matters in
instances in which there is inadequate expertise at regional and local level.
The
minority is of the view that the majority's recommendation could have serious
consequences
for the continued operation of NBTS.
The
minority recommends that the medical assistance presently offered at NBTS is
strengthened.
A second
minority recommends that to service all diagnoses relating to gender identity
disorders
in ICD-10, the present national treatment service should be changed to a
multiregional
treatment
service that shall only be established at two health trusts and which can
assess and
treat all diagnoses within gender identity disorders in ICD-10. In other words,
in
practice
the activities at OUS will be continued and treatment services will be
established at
additional
health trusts. With an extremely small patient volume, treatment services at
two
health
trusts will be sufficient for servicing all groups who are currently assessed
and
diagnosed
with F.64.0, F.64.2, F.64.8 and F.64.9. This will also make a second opinion
possible in
Norway. NBTS, OUS will retain responsibility for the treatment service for
F64.0
In the
recommendations that apply to the services offered by the specialist health
service to
children
and adolescents, the expert group has divided into a majority and a minority.
When there
is a need to assess and treat children and adolescents at specialist health
service
level, it
is the view of the majority that this should, as a main rule, occur under the
direction
of the
regional health trusts. Children and adolescents should only be referred to
NBTS when
there is a
need for highly-specialised expertise.
The
minority is of the view that the majority's recommendation for treatment of
children
with gender
dysphoria will result in the discontinuation of the present national treatment
service for
children with gender dysphoria. The minority makes reference to the fact that
since 2005,
NBTS has developed a treatment option with highly-qualified health personnel
with
expertise in servicing children with gender dysphoria and is the only place in
Norway
with
multi-disciplinary specialist expertise in the treatment of children.
The
majority recommends that the regional health trusts be responsible for
providing
endocrinological
treatment and other necessary medical assistance to children and
adolescents
who suffer from distress and discomfort due to gender incongruence. If the
needs of
the patient can only be met by highly-specialised expertise, the patient must
be
referred to
NBTS. The minority recommends that the present treatment for children with
gender dysphoria at
NBTS must
be strengthened. The minority considers it important to build up the expertise
at
one or a
maximum of two health trusts to be able to ensure that children have the
continuity
in their treatment that is decisive to them receiving safe and correct
professional
treatment.
In the view of the minority, the number of children with gender dysphoria is
too
low to
justify the establishment of treatment services at more health trusts. The
minority
considers
it important that children are closely monitored locally and that children are
regularly
followed-up by NBTS and possibly by additional health trusts.
National
guidelines
The
decision regarding the medical assistance that is to be offered shall be made
by qualified
health
personnel after a professional assessment in consultation with the patient. The
lack
of clear,
transparent and professional reasons for identifying who is considered to
benefit
from gender
confirming medical assistance may have contributed to people who experience
gender
dysphoria not seeking medical assistance or some people receiving more
treatment
than they
in fact required.
The expert
group's work has highlighted a major need for systematising and clarifying the
content of
the medical assistance to people with gender dysphoria
The expert
group recommends that national guidelines are prepared for medical assistance
to people
who experience gender dysphoria.
Sterilisation
and castration
The
individual's experience of having primary gender characteristics that do not
match their
own gender
identity or gender expression can be a strain that may result in the need for
undergoing
a castration procedure as part of the gender confirmation process.
The expert
group recommends that the general rules in the Act relating to patient and user
rights is
used as a basis if a person wishes to undergo castration/sterilisation in
connection
with gender
confirmation treatment. Due to the nature of the procedure, an age limit of 18
years
should apply.
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