Conditions for changing legal gender //

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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.