Gender-affirming care
KEY FIGURES
Waiting time
Hormonal therapy: 11-16 months
Gender affirming bottom surgery:
4-6 years (transgender women)
2-3 years (transgender men)
Source: Center for Gender Identity, Rigshospitalet, June 2023. Patients living in Copenhagen (hormonal therapy) or any part of the country (bottom surgery).
Treatment abroad
42 % of transgender persons who have received gender affirmation treatment have applied for treatment abroad.
18 % of transgender persons who have received gender affirmation treatment have practised self-medication.
Source: Johansen et al. (2015).
Treatment for intersex persons
Unknown.
Number of appointments, type of therapy and follow-up, and satisfaction with treatment.
- In the past five years, Danish centres offering treatment for transgender and nonbinary persons have increased in number from one to three. This enables the Danish healthcare system to treat a larger number of transgender and nonbinary persons.
- Transgender and nonbinary persons, especially those wanting bottom surgery, have to wait a long time for treatment. This may greatly affect their mental health.
- Waiting time can make transgender and nonbinary persons resort to self-medication without professional supervision. Others pay for treatment abroad. In both cases, the patient may require follow-up in the Danish healthcare system.
- There is very little available knowledge of persons with variations in sex characteristics, including intersex persons, and their interaction with the Danish healthcare system.
Editing was completed September 2023
Transgender and nonbinary persons constitute a very diverse group with very different needs. The majority of transgender and nonbinary persons request treatment – in the form of hormonal therapy or surgery – to achieve a gender expression that matches the gender they identify with. Few do not want any treatment. A survey from 2015 conducted by the National Institute of Public Health finds that 14 % of the participating transgender persons do not want treatment, while the majority (79 %) say that they either want or are undergoing treatment.
All types of treatment for transgender and nonbinary persons are performed centrally in the healthcare system. Treatment in one of the country’s three centres for gender identity requires a referral from the patient’s GP. Hereafter follows interviews with a psychologist, physiatrist and doctor followed by an assessment of the need for further treatment.
The Copenhagen Sex Clinic offers nonsurgical treatment of persons below the age of 18 from all over the country. Treatment consists of interviews and hormonal therapy. Gender affirmation surgery is not available to persons below the age of 18.
The three centres for gender identity in Aalborg, Odense and Copenhagen, respectively, offer treatment for persons aged 18 years or more. Treatment consists of interviews, group interviews, laser treatment, makeup courses, hormonal therapy, top surgery (removal or augmentation of breasts) and bottom surgery (removal or augmentation of internal or external genitals or removal of reproductive organs). Gender affirming bottom surgery requires specialised expertise and is only performed at Rigshospitalet. The hospital only performs a small number of gender affirmation operations a year. Private hospitals in Denmark are not allowed to offer gender affirmation surgery.
In recent years, the three Danish centres for gender identity have seen an increase in persons requesting treatment for gender dysphoria and who have been referred by their GP. Around 1,000 persons a year apply for treatment in one of the three centres for gender identity. The increase in patients is related to the fact that patients who e.g., receive hormonal therapy get regular follow-ups. This means that the number of patients who start treatment exceeds the number of patients who complete treatment.
The table below lists the waiting time for interviews and bottom surgery at the Center for Gender Identity (CKI) at Rigshospitalet. There are no statistical data for the three centres for gender identity. Treatment typically includes several interviews, therapy and waiting time and is a long proces.
We cannot say anything about the actual course of treatment. An older survey of the total course of treatment in 98 % of cases of gender affirmation treatment in the period 1978-2008 shows that treatment took 8.1 years for transgender women – before undergoing bottom surgery – and 5.9 years for transgender men. However, the area has seen progress in recent years.
In 2022, the total waiting time for surgical removal of the male genitals and neo-vagina construction was approx. 4-6 years, according to CKI in Copenhagen. In a recent case from 2023 a patient’s request for bottom surgery was granted – with effect within six years. See the fact box below.
Long waits due to the large number of referrals and capacity issues can have negative consequences. The mental health of transgender persons who have to wait a long time for treatment may be severely impaired. Some give up and look for alternatives outside the healthcare system.
Waiting time
“In connection with my treatment, I had to play the typical man. I soon learned to provide the right ‘male’ answers in a heteronormative sense, and I dressed in a more masculine fashion.”
- Norr (LGBT+-person)
Long waiting time or a desire to avoid the Danish healthcare system may cause some transgender or nonbinary persons to look for treatment options abroad. Some get a referral from the Danish healthcare system; others arrange and pay for treatment themselves.
In a representative survey from 2015 about LGBT health, 42 % of the 72 participating transgender persons who have undergone gender affirmation treatment say that they were treated abroad. The majority of those who received treatment abroad paid for it themselves.
The same survey shows that 18 % of the 149 participating transgender persons practised self-medication without consulting a doctor.
These figures are not up-to-date, and recent years have seen large-scale reorganisation and an increase in treatment for transgender and nonbinary persons. The figures for self-medication correspond with a recent assessment by the medical director of the Center for Gender Identity in Aalborg, who finds that 20 % of those treated at the clinic practise self-medication in the form of e.g. hormonal therapy.
In a non-representative survey from 2021 on gender affirming bottom surgery among 188 transgender persons, around two in three say that they wish they were able to get one or more bottom surgery procedures abroad.
Waiting time, lack of confidence in health professionals and fear of or experiences with uncomfortable interaction with health professionals in Denmark are among the most frequently cited reasons why transgender and nonbinary persons seek treatment abroad – according to the 2015 survey.
However, there is reason to believe that most of those who receive treatment are satisfied with it. 75 % of the respondents in a patient satisfaction survey conducted by the Center for Gender Identity in 2021 say that their interaction with the centre has been a positive experience.
Transgender and nonbinary persons who seek treatment abroad are willing to pay for the same costly treatment they in some cases are entitled to in the Danish healthcare system. Others have doubts as to the quality of the treatment offered in Denmark. Furthermore, transgender and nonbinary persons who self-medicate with hormones purchased abroad run a risk due to the lack of medical supervision.
In a complaint case settled by the Danish Patient Complaints Agency in March 2023, a person (the complainant) had been approved for gender affirming bottom surgery (removal of female genitals and penis construction) and offered treatment in Denmark within six years. Due to the long wait, the complainant applied for preliminary approval for treatment in Germany to reduce the wait.
The region rejected the application, as treatment within six years was considered timely. What constitutes timely treatment is unclear.
The Danish Patient Complaints Agency reversed the region’s decision, which gave the complainant the right to treatment abroad.
The Agency’s decision was based on a Lithuanian case, where a wait for gender affirmation treatment exceeding four years was considered a violation of article 8 of the European Convention on Human Rights (right to respect for one’s private and family life).
Treatment abroad
“Getting the operation was a completely crazy experience. Before that I thought about taking my own life. So, getting gender affirmation treatment has saved my life. Now I can look myself in the mirror and recognise myself.”
- Norr (LGBT+-person)
1.7 % of new-borns have intersex variations. We know very little about intersex persons’ interaction with the healthcare system, including contact with doctors and hospitals, treatment forms (hormonal therapy or surgery), follow-up and patient satisfaction. There are no national guidelines for diagnostics, treatment and follow-up for persons with variations in sex characteristics (e.g. Turner syndrome, Klinefelter syndrome and adrenogenital syndrome).
Since 2014, cosmetic surgery on persons below the age of 18 has been against the law – except for health reasons. Previously, the idea was that the gender of the child should be established, and any surgical procedures be undertaken as soon as possible after birth. We do not know how many children were subjected to unnecessary or cosmetic surgery prior to 2014.
In 2019, the UN Committee for Economic, Social and Cultural Rights expressed concern for Denmark’s treatment of intersex children’s rights. This included concern as to whether Danish doctors continue to perform medically unnecessary operations on intersex children. At the same time, the Committee encouraged Denmark to train its health professionals in the health needs and rights of intersex persons and to adopt a broader understanding of intersex.
Furthermore, the UN Committee for Economic, Social and Cultural Rights emphasised that the concept of DSD – Disorders (differences) of Sex Development – used in Denmark is too narrow and does not cover all intersex conditions. There is disagreement both at national and international level, between medical organisations and organisations protecting the rights of intersex persons, about how to define the group. Also in 2019, the Danish Paediatric Society published a set of clinical guidelines for treatment of persons with DSD.
The Danish Health Authority stresses that surgery must be based on health grounds and thorough medical consideration, and that doctors are not allowed to perform cosmetic or unnecessary surgery on children and youth with variations in sex characteristics.
A series of European countries, including Germany, Iceland, Portugal, Spain and Malta, have banned surgery on intersex children which, if violated, can lead to fines and criminal penalties.
The Danish Health Authority has created a theme page about variations in sex characteristics which i.a. provides facts, figures and descriptions of conditions, diagnostics and treatment.
The page also contains an information leaflet for parents of children born with variations in sex characteristics.
The first of its kind survey of living conditions of persons born with variations in sex characteristics, which includes a qualitative study with interviews of 14 individuals and a survey of national and international literature, shows that interaction between the healthcare system and this group faces two main challenges: consent to treatment and lack of information about objectives, consequences and side effects of treatment.
Intersex Denmark calls attention to the existence of persons born with variations in sex characteristics and strives to protect their rights, both at national and international level. Read more about the association on their website.