Teenagers, Children, and Gender Transition Policy: A Comparison of Transgender Medical Policy for Minors in Canada, the United States, and Europe 

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Introduction

The belief that biological sex and gender are social constructs (i.e., that they are merely the product of social norms, not nature) has made its way into American classrooms,¹ courtrooms,² bathrooms,³ and boardrooms.⁴ The same holds true for Canada. The wide acceptance of this belief system has coincided with a substantial increase in the number of children receiving transgender medical care. Between 2017 and 2021, the number of children known to be on puberty blockers or cross-sex hormones more than doubled.⁵ During the same period, the number of children diagnosed with gender dysphoria tripled.

Skeptics have raised the alarm, pointing out that the surge in sex reassignment interventions (i.e., puberty blockers, cross-sex hormones, and sex reassignment surgeries) might be explained, at least in part, by social contagion. According to this argument, the increase in interventions among adolescents is caused not by a genuine increase in the incidence of gender incongruence but by the spread of gender ideology across all facets of life. This concern is exacerbated by the degree to which the medical establishment allows such ideology to compete with or even usurp the scientific method as a guide to research and medical practice.⁶

The North American approach to transgender medical treatment for children is known as “gender affirmation,” which assumes that gender incongruence can manifest as early as age four and that questioning a minor’s gender self-definition is harmful and unethical. The American Academy of Pediatrics has embraced an affirm-only/affirm-early policy since 2018,⁷ and most states and provinces abide by its guidance, despite medical and scientific criticism; gender-affirming care is standard across most of the United States and Canada.

On the other hand, Northern and Western Europe, which broadly share the same social values as Canada and the United States, have begun to reject the gender-affirming care model for children. In fact, several countries, including the United Kingdom, Sweden, and Finland, have explicitly abandoned it in recent years in part due to the fear that medical intervention has become overprescribed (studies show that only 12 to 27 percent of cases of childhood gender dysphoria persist into adulthood).⁸ In a sharp departure from the gender affirmation model employed in North America, European countries now discourage automatic deference to a child’s self-declaration of gender distress, while also calling for months-long psychotherapy sessions to address co-occurring mental health problems. Notably, the United Kingdom’s Cass Review blamed the lack of safeguards for children at its largest pediatric gender centre on the “affirmative model” which originated in the United States.⁹

The different approaches between North America and Europe lead to a concerning reality: In Canada and the United States, patients are eligible for invasive surgeries and/or potentially irreversible and medically harmful dispensation of puberty blockers and cross-sex hormones at a much younger age than is the case in Europe.

This report identifies the different legal requirements for gender change-related treatments and actions in North American and in Western and Northern European countries. Most of the information contained in this report includes references with web links to the original sources. Some information was procured through consultation with local experts, often though not exclusively an individual affiliated with a gender clinic. In the interest of their privacy, we have kept their identities anonymous.

Overall, our policy review reveals that Canada and the United States are the most permissive countries when it comes to the legal and medical gender transition of children. The only other country to come close is France, yet unlike North America, France’s medical authorities have recognized the uncertainties involved in transgender medical care for children and have urged “great caution” in its use.

Given the growing body of evidence and the European consensus, which is grounded in medical science and common sense, in the interests of protecting the youngest and most vulnerable patients, Canada and the United States should reconsider the gender-affirming care model.

1. Legal requirements to change gender

CONTEXT: Many jurisdictions now allow individuals to change the gender that is listed for them on government-issued documents. The requirements imposed on civil registries to recognize individuals as belonging to a gender other than their biological sex sheds light on the degree to which gender affirmation is established in law.

North America

Western and Northern Europe

Belgium	Gender changes in the civil registry are self-determined.25
Denmark	Gender changes in the civil registry are self-determined.26
Finland	Adults (18 and older) can apply for a gender change to the civil registry but must undergo a 30-day period of reflection.27
France	Individuals wishing to change their gender in the civil registry must prove that they socially live as the other gender. Evidence may include family testimonies, photographs, and medical certificates. One piece of evidence is not enough.28
Germany	Gender changes in the civil registry are self-determined.29
Iceland	Gender changes in the civil registry are self-determined.30 Adults can only change their gender once.31
Ireland	Gender changes in the civil registry are self-determined.32
Luxembourg	“Sufficient evidence must be presented to show that the gender status currently recorded in the civil register does not reflect their gender identity. Such evidence may include: The fact that the person’s gender expression matches the gender being applied for; the fact that the person is identified by their family, friends and acquaintances as the gender being applied for; the fact that the minor has previously obtained a change in first name to match the gender being applied for.”33
Netherlands	The government requires a statement from a doctor, psychologist, or psychotherapist that affirms “that you (the applicant) have declared to this expert that you have the permanent conviction that you belong to another gender than stated on your birth certificate. And that you understand the repercussions of your decision to change your gender identification.”34
Norway	Gender changes in the civil registry are self-determined.35
Sweden	Gender changes in the civil registry are self-determined.36
United Kingdom	Applicants must have a diagnosis of gender dysphoria from a doctor, live as the “affirmed” gender for at least two years, and intend to live in that gender for the rest of their life. The requirement that one have a dysphoria diagnosis can be waived if the applicant has been living in their affirmed gender for at least six years and had gender affirmation surgery.37

2. Minimum age to change gender in the civil registry

CONTEXT: Some jurisdictions allow individuals to change their gender identity on government-issued documents. But not all of them let minors do this and practices vary across the jurisdictions that permit it.

North America

Canada
Alberta	No age minimum, though parental consent is required until 18.38
British Columbia	Applicants under 19 are required to submit a consent form from their parents or guardians. For children younger than 11, BC requires that a letter be submitted from a physician or psychologist, but as of 2022 this is not needed for applicants 12 and older.39
Manitoba	No age minimum, though for applicants under 17, a physician’s letter is required that includes their confirmation of the applicant’s mental acuity.40
New Brunswick	No age minimum, though parental consent is required until 15.41
Newfoundland & Labrador	No age minimum, though parental consent is required until 16.
Nova Scotia	No age minimum, though parental consent is required until 15. 42,43
Ontario	No age minimum, though parental consent is required until 15.44
Prince Edward Island	No age minimum, though parental consent is required until 18, and the applicant’s written consent is also required if they are older than 12.45
Quebec	No age minimum, though parental consent is required until 14.46
Saskatchewan	No minimum age requirement, but Saskatchewan does require a supporting letter from a health care professional for all ages.47

United States

The approach in the United States is piecemeal as both states and the federal government are custodians of civil registration. There is no minimum age for changing gender on passports48 or in Social Security Administration (SSA) documentation.49 For minors, changes to either document require the consent of both parents. Some states, including New York, California, Colorado, Connecticut, New Jersey, Pennsylvania, and Washington, permit minors to change their birth certificate gender markers with parental consent.50

Western and Northern Europe

Belgium	Minors aged 16 or 17 must obtain parental consent and consult with a psychiatrist.51
Denmark	The limit is currently age 18, though there is an ongoing political debate about lowering the age.52
Finland	The minimum age requirement is 18.53
France	The minimum age requirement is 18.54
Germany	The minimum age is 14 with parental consent or following the recommendation of a family court. Those under 14 must have parents file the application on their behalf.55
Iceland	Iceland requires parental consent for a change of gender under the age of 15; minors older than 15 can request a committee review their case if they do not have parental approval.56
Ireland	Gender changes in the civil registry An individual who is 16 or 17 must have parental consent, approval from a medical practitioner, and an application to the High Court, otherwise, the requirement is 18 years of age.57
Luxembourg	There is no age limit. For youth under age 5, applications are sent to the Ministry of Justice. For youth over age 5, applications are sent to the “competent district court.” Parental consent is required until age 18.58
Netherlands	The government requires a statement from a The minimum age requirement is 16, although minors (ages 16 or 17) must apply through a court.59
Norway	Changes are possible, with parental consent, from age 6. Without parental consent, a person must wait until age 16.60
Sweden	The minimum age requirement is 16, though minors (ages 16 or 17) need approval from a guardian, a doctor, and the National Board of Health and Welfare.61
United Kingdom	There is no age minimum, though parental consent is required up until age 18.62

3. Legal gender other than male or female

CONTEXT: Some jurisdictions recognize a gender other than male or female thereby tacitly endorsing the idea that gender and sex are social constructs (in other words, not biological facts but imposed norms, agreed upon by society).

North America

Canada
Alberta	Allows an X marker on IDs in addition to the conventional male and female category.63
British Columbia	Allows an X marker on IDs in addition to the conventional male and female category.64
Manitoba	Allows an X marker on IDs in addition to the conventional male and female category.65
New Brunswick	Allows an X marker on IDs in addition to the conventional male and female category.66
Newfoundland & Labrador	Allows an X marker on IDs in addition to the conventional male and female category.67
Nova Scotia	Allows an X marker on IDs in addition to the conventional male and female category.68
Ontario	Allows an X marker on IDs in addition to the conventional male and female category.69
Prince Edward Island	Allows an X marker on IDs in addition to the conventional male and female category.70
Quebec	Allows M, F, and X as legal gender markers on documents.71
Saskatchewan	Allows an X marker on IDs in addition to the conventional male and female category.72

United States

Twenty-two states as well as the District of Columbia (DC) allow individuals to place an X (rather than an M or F) on a driver’s license; 16 states plus DC allow it on birth certificates. Passports offer an X gender option.73

Western and Northern Europe

Belgium	The government only recognizes male and female, though gender has been removed altogether from identity cards.74
Denmark	Denmark allows an X marker on IDs, but the civil registry is binary.75
Finland	Male and female are the only recognized genders.76
France	Male and female are the only recognized genders.77
Germany	Germany allows for a third gender designation.78
Iceland	Iceland allows for third gender and/or nonbinary designations.79
Ireland	Ireland allows a third gender option on passports but not in the civil registry.80
Luxembourg	Male and female are the only recognized genders.81
Netherlands	Gender neutral designation on official documents is possible, but only through request to a district court.82
Norway	Male and female are the only recognized genders.83
Sweden	Male and female are the only recognized genders.84
United Kingdom	Male and female are the only recognized genders.85

4. Notable requirements for medical transitions

CONTEXT: Recognizing that gender-affirming care is largely irreversible and that only 12 to 27 percent of cases of childhood gender dysphoria persist into adulthood, 51 some jurisdictions impose barriers to medical intervention. These barriers are intended to screen out cases that are unlikely to persist or in which mental distress would not be improved through sex trait modification.

North America

Canada	Note: No province or territory in Canada allows “bottom” (male or female genital reassignment) surgery for applicants under the age of 18. Most guidelines in Canada are adopted from World Professional Association for Transgender Health (WPATH) criteria.86
Alberta	In a recent announcement, Alberta Premier Danielle Smith indicated that no Albertan under the age of 18 will have access to top or bottom surgery.87 For phalloplasty, metoidioplasty, and vaginoplasty, the applicant requires two gender dysphoria diagnoses from two psychiatrists or mental health specialists.88
British Columbia	To qualify for genital surgery, six months of hormone therapy is required prior to surgery. British Columbia no longer requires previous congruent living (i.e., living as the gender with which you identify) to access genital surgery. As of February 2023, one recommendation letter is needed for genital surgery (two were required before that date). The age of access for lower (bottom) genital surgery is 19; top surgery is allowed on minors with consent of the applicant or their guardians, depending on their assessed capability.89
Manitoba	To qualify for surgery, the province requires a referral letter by an approved Manitoba psychologist and health practitioner. To qualify for top surgeries (mastectomy, chest masculinization, etc.), no previous hormone replacement therapy is required. To qualify for bottom surgeries (hysterectomy, oophorectomy, etc.), at least one year of hormone replacement therapy is required prior to surgery. Most bottom surgeries are not provided in Manitoba; applicants are referred to Quebec.90
New Brunswick	For top surgery, a referral letter from one mental health professional is required, but no hormone replacement therapy is required. By contrast, for bottom surgery, the applicant must pursue hormone replacement therapy for a minimum of one year prior to surgery and provide two recommendation letters in support of surgery. Like other jurisdictions, diagnoses of persistent gender dysphoria (DSM-5) are required for top and bottom surgery.91
Newfoundland & Labrador	The applicant is required to demonstrate the ability to provide consent and must also provide a recommendation letter from a medical professional for top and bottom procedures. The patient must also have persistent and well documented gender dysphoria. For breast augmentation and aplasia, 18 continuous months of hormone therapy is recommended. For genital and genital reconstructive surgery, 12 continuous months of hormone replacement therapy is required, as is 12 continuous months of living in the gender expression that is congruent with gender identity.92
Nova Scotia	To be eligible for genital surgery the applicant must be at least 18 years or older at the time of surgery, and the application must be signed by a Nova Scotia physician, nurse practitioner, or specialist. The applicant must have one psychosocial assessment letter signed by a WPATH-accredited professional and provide a letter from a specialist that verifies post-care arrangements. If an adolescent age 16 to 18 is requesting an exemption, they must demonstrate to their health care provider an emotional and cognitive maturity to provide informed consent. Persistent gender dysphoria is also a requirement for surgery.93
Ontario	To qualify for genital surgery the applicant needs two assessments recommending surgery (one must be from a doctor or nurse practitioner). These assessments must confirm that the applicant has been on hormone therapy for 12 continuous months, has been diagnosed with persistent gender dysphoria, and has lived for at least 12 months in the gender role with which they identify. To qualify for chest surgery, the applicant needs only one assessment from a doctor and does not need to prove that they have lived in the gender role with which they identify.94
Prince Edward Island	To be eligible, the applicant must be recommended by a qualified physician or nurse practitioner.95 The applicant must be at least 18 years old and have been on hormone therapy for at least six months prior to surgery.96
Quebec	Quebec has no minimum age for gender transitions but applicants must be 16 years old for double mastectomies and 18 for genital surgeries.97 To qualify for surgery, the applicant must provide two recommendation letters from a psychologist, psychiatrist, or sexologist. The first letter must be provided by a specialist that has followed the applicant’s case for a minimum of six months, while the second must simply approve the content of the first letter. A certificate of good health is also required to certify the applicant’s ability to undergo surgery.98
Saskatchewan	Top surgeries require the referral of one general practitioner without the need of diagnosed gender dysphoria. For bottom surgeries such as hysterectomy (removal of uterus and ovaries) and orchiectomy (removal of testicles), the applicant must demonstrate more than one year of living in a gender role congruent with their identity in addition to more than one year of being on hormone therapy (if applicable).99

United States

A diagnosis of dysphoria is required for insurance purposes, but an individual paying out-of-pocket could medically transition without such a diagnosis.100 A diagnosis is typically, though not exclusively, made by a psychologist or psychiatrist. Testosterone is a controlled substance, so depending on state law there are restrictions on which practitioners can prescribe it. Clinics that use WPATH guidance impose few or no other limitations to receiving hormonal or physical treatment. For example, the transgender clinic at the University of California San Francisco advises that “Medical providers who feel comfortable making an assessment and diagnosis of gender dysphoria, as well as assessing for capacity to provide informed consent (able to understand risks, benefits, alternatives, unknowns, limitations, risks of no treatment) are able to initiate gender affirming hormones without a prior assessment or referral from a mental health provider… Prescribing gender affirming hormones is well within the scope of a range of medical providers, including primary care physicians, obstetricians-gynecologists, and endocrinologists, advanced practice nurses, and physician assistants. Depending on the practice setting and jurisdiction, other providers with prescriptive rights (naturopathic providers, nurse midwives) may also be appropriate to prescribe and manage this care.”101

Western and Northern Europe

Belgium	Minors seeking gender-affirming health care must undergo repeated consultations with psychiatrists and endocrinologists.102
Denmark	A “thorough” psychiatric evaluation and a “broad diagnostic” interview are required. A multidisciplinary team consisting of pediatric endocrinologists, psychiatrists, and psychologists determine the appropriate course of care.103
Finland	The dysphoria of a minor seeking hormone treatment must be deemed “severe” and “permanent.” Prescription of puberty blockers or cross-sex hormones to minors requires that no contraindications to early treatment are identified.104
France	Most health care providers require a psychological assessment before prescribing hormonal treatments.105
Germany	Hormone therapy generally requires a letter of recommendation from a psychotherapist.106
Iceland	Individuals who want hormone treatment are observed for at least six months to ensure that they are psychiatrically fit to receive treatment.107
Ireland	Individuals seeking gender-affirming surgery or hormones must receive a dysphoria diagnosis and live full-time as their preferred gender identity for a significant period. An individual seeking sex-reassignment surgery must obtain the approval of a psychiatrist or psychologist.108
Luxembourg	Luxembourg does not offer a pediatric gender-affirming service. Patients generally seek treatment in neighboring countries.109
Netherlands	Practitioners are largely deferential to the Endocrine Society 2017 clinical practice guideline and WPATH Standards of Care 7 (i.e., the barriers to gender-affirming care are minimal).110
Norway	If diagnosed with transsexualism, the patient undergoes a “real-life experience” for a minimum of 12 months, during which time the person lives in accordance with their gender identity. After the real-life experience and endocrine and other metabolic examinations, the patient is prescribed hormones. Patients are assessed for surgery after one to three years of hormone therapy.111
Sweden	Requires a diagnosis of gender dysphoria (DSM-5) and treatment from an interdisciplinary medical team. “The key prerequisite for hormonal treatment of youth is the prepubertal onset of gender dysphoria that is long-lasting… persists into adolescence, and causes clear suffering.”112
United Kingdom	Male and female are the only recognized genders. Puberty blockers are no longer available to minors as a treatment for gender dysphoria. Inclusion criteria for hormone replacement therapy include assessment by a multidisciplinary team “over a period of time,” regularly attending appointments with the care team, good physical health, assessment that the minor can provide informed consent, observation that “associated difficulties” such as psychotic episodes, drug addiction, and self-harm are not intensifying. Exclusion criteria include concerns about physical health (e.g., low bone density) or “significant psychotic episodes” or other mental health disorders that are not “adequately controlled.”113

5. Minimum age for puberty blockers

CONTEXT: Puberty blockers suppress the release of sex hormones so that gender-questioning youth do not sexually develop in a way that diverges from their gender identity. For gender-questioning youth that are young enough to receive them (they are not administered to individuals who have reached full sexual maturation), puberty blockers are the first medical intervention administered. Blockers are known to decrease bone density and contribute to infertility when administered alongside cross-sex hormones. They may also inhibit cognitive development.

North America

Canada
Alberta	Puberty blockers are banned for those younger than 15.114
British Columbia	There is no age restriction on puberty blockers, but if the applicant is younger than 19, they are required to demonstrate a long-lasting and intense pattern of gender dysphoria alongside coexisting psychological, medical, and social problems. Parental consent is not required for puberty blockers.115
Manitoba	No minimum age requirement is suggested but the applicant must meet the WPATH requirements: • Informed consent and consent of guardians if below the age of medical consent • Any co-existing psychological, medical, or social problems that could interfere with the treatment have been addressed • Worsening of gender dysphoria with the onset of puberty • Long-lasting and intense patterns of gender dysphoria116
New Brunswick	No age requirements for puberty blockers, but the referring physician will use WPATH criteria to assess eligibility.117
Newfoundland & Labrador	No age requirements for puberty blockers, but the referring physician will use WPATH criteria to assess eligibility.118
Nova Scotia	Applicants are required to reach Tanner Stage II (minimum), in addition to meeting WPATH criteria to be eligible for puberty blockers.119 Tanner Stage II is generally marked by 11½ to 12 years of age.120
Ontario	No age restrictions on puberty blockers; in fact, in some cases children have been allowed to take them before a first clinical assessment.121
Prince Edward Island	No age requirements for puberty blockers, but the referring physician will use WPATH criteria to assess eligibility.122
Quebec	No minimum age requirement is suggested but the applicant must meet the WPATH requirements.123
Saskatchewan	No age requirements mentioned for the use of puberty blockers, but the applicant must meet WPATH criteria before using them: • Informed consent and consent of guardians if below the age of medical consent • Any co-existing psychological, medical, or social problems that could interfere with the treatment have been addressed • Worsening of gender dysphoria with onset of puberty • Long-lasting and intense patterns of gender dysphoria124

United States

Some states restrict access to puberty blockers for minors and lawmakers in other states seek such restrictions.125 Elsewhere, blockers can be administered from the earliest stages of puberty. According to the New York Times, “Many physicians in the United States and elsewhere are prescribing blockers to patients at the first stage of puberty — as early as age 8.”126 In most states, puberty blockers cannot be administered before age 18 without parental consent. Oregon is a notable exception: Children are legally entitled to receive puberty blockers from age 15 onwards, and they receive Medicaid assistance in doing so.127

Western and Northern Europe

Belgium	Puberty blockers are available with parental consent from Tanner Stage II and without parental consent at age 18.128
Denmark	Puberty blockers can be prescribed from age 12 with parental consent129 and from age 15 without parental consent.130
Finland	Puberty blockers are available from age 13 with parental consent, and from 18 without consent.131
France	In theory, puberty blockers could be prescribed for minors at any age, though in practice it is not done until Tanner Stage II.132 Blockers are available without consent from age 18.133
Germany	Treatment with puberty blockers is at the discretion of the medical professional but can be prescribed from the age of 12.134
Iceland	There is no minimum age for puberty blockers with parental consent, so the minimum age is a matter of clinical judgement. Adolescents 15 and younger must obtain parental consent, though they can appeal to the ombudsman for children and receive government permission to bypass parental consent.135
Ireland	Individuals seeking gender-affirming sIreland Puberty blockers are available to those “under 16 years old” with consent, and age 16 and over without consent.136
Luxembourg	No official guidance exists. In practice, adolescents almost always receive blockers in a neighbouring country because there is no pediatric gender-affirming service in Luxembourg.137
Netherlands	According to protocol, blockers are available from age 12 without consent,138 though younger cases have been recorded. Blockers are available without consent from age 16.139
Norway	Puberty blockers are available with consent once the physiological signs of puberty manifest.140 They are available without consent from age 16.141
Sweden	Puberty blockers were previously prescribed from age 12 with parental consent and from 18 without consent.142 In 2022, Sweden issued new guidelines limiting the use of puberty blockers for minors to “exceptional cases.”143
United Kingdom	Until 2024, puberty blockers were available from the earliest stages of puberty, with or without parental consent,144 with rare instances reported of children under 16 receiving blockers without consent.145 But on March 12, 2024, England banned146 and on April 18, 2024, Scotland paused147 puberty blockers for minors under 18.

6. Minimum age for cross-sex hormones

CONTEXT: Medical intervention can include cross-sex hormone therapy, whereby sex hormones (estrogen or testosterone) are administered to alter a person’s secondary sex characteristics to better align with their gender identity. Observational analysis indicates that biological males who receive hormone therapy might be at elevated risk for cardiovascular problems.¹⁴⁸ Some of the changes brought about by hormone therapy are irreversible.¹⁴⁹

North America

Canada
Alberta	Cross-sex hormones are banned for those younger than 16 years old.150
British Columbia	Cross-sex hormones can be prescribed at any age with the patient’s informed consent. In 2020, the BC Court of Appeals declared that trans teens can seek hormone treatment without parental consent.151
Manitoba	No minimum age requirement is suggested for the prescription of cross-sex hormones but the applicant must meet the WPATH requirements: • Informed consent and consent of guardians if below the age of medical consent • Any co-existing psychological, medical, or social problems that could interfere with the treatment have been addressed • Worsening of gender dysphoria with the onset of puberty • Long-lasting and intense patterns of gender dysphoria152
New Brunswick	Cross-sex hormones can be prescribed at any age with the informed consent of the patient.153
Newfoundland & Labrador	There are no age requirements for the prescription of cross-sex hormones, but the referring physician will use WPATH criteria to assess eligibility.154
Nova Scotia	Applicants are required to reach Tanner Stage II (minimum), in addition to meeting WPATH criteria to be eligible for cross-sex hormones.155 Tanner Stage II is generally marked by 11½ to 12 years of age.156
Ontario	No legislated minimum age requirement for the prescription of cross-sex hormones.157
Prince Edward Island	No age requirements for cross-sex hormones, but the referring physician will use WPATH criteria to assess eligibility.158
Quebec	No minimum age requirement is suggested. Reports suggest that patients can be prescribed cross-sex hormones within minutes without any referral letters from a psychologist or medical professional.159
Saskatchewan	Cross-sex hormone therapy can begin at 16 years of age.160

United States

Some states restrict access by minors to gender-affirming hormone treatment, and lawmakers in other states are considering restrictions. In some states, the practice has been documented with parental consent for children under the age of 13.161 Oregon is the most permissive state, with minors able to access cross-sex hormones from age 15 without consent and with Medicaid assistance.162

Western and Northern Europe

Belgium	Cross-sex hormones are available from age 16 with parental consent163 or 18 without consent.164
Denmark	here is no minimum age for cross-sex hormones for minors who have parental consent.165 Hormones are available from age 15 without parental consent.
Finland	Cross-sex hormones are available from age 16 with parental consent166 or 18 without consent.167
France	There are no age restrictions on the use of cross-sex hormones with parental consent.168 The use of these hormones for those under age 18 requires parental consent.169
Germany	Treatment with puberty blockers is at the discretion of the Germany Cross-sex hormone treatment can be started at age 16. Parental consent is required under 18.170
Iceland	Available from age 16 with or without parental consent.171
Ireland	Available from age 16 with or without parental consent.172
Luxembourg	No official guidance exists. Patients almost always receive hormones in a neighbouring country because there is no pediatric gender-affirming service in Luxembourg.173
Netherlands	Cross-sex hormones are available from age 16 with or without parental consent, though younger cases have been documented in adolescents with consent.174
Norway	Norway Available from age 16 with or without parental consent. However, consent is required for individuals 16 to 18 if the treatment is considered irreversible.175
Sweden	Sweden No longer available for anyone under the age of 18 with the exception of research settings. Consent not required after age 18.176
United Kingdom	Available “around” an individual’s 16th birthday with or without parental consent.177

7. Minimum age for sex-reassignment surgery

CONTEXT: For some gender-questioning individuals, intervention culminates with sex-affirming surgeries, including mastectomy (breast removal), hysterectomy (uterus removal), vaginoplasty (vagina creation), and phalloplasty (penis creation). These dramatic physical alterations are largely irreversible.

North America

Canada
Alberta	Minimum age for sex reassignment surgery in Alberta is 18.178
British Columbia	Minimum age for (bottom) sex reassignment surgery in BC is 19.179
Manitoba	The age of medical consent is 18 years old but, similar to other jurisdictions, minors deemed capable of making informed decisions can do so without parental consent.180
New Brunswick	The age of medical consent is 18 years old but, like other jurisdictions, minors deemed capable of making informed decisions can do so without parental consent.181
Newfoundland & Labrador	The age of medical consent is 18 years old but, like other jurisdictions, minors deemed capable of making informed decisions can do so without parental consent.182
Nova Scotia	The applicants must be 18 years or older at the time of sex-reassignment surgery. Chest surgeries can be requested at the age of 16.183
Ontario	Minimum age for sex reassignment surgery in Ontario is 18.184
Prince Edward Island	The applicant must be at least 18 years of age at the time of surgery.185
Quebec	The required age for genital reconstructive surgery is 18 years of age; 16 for a mastectomy.186
Saskatchewan	Minimum age for sex reassignment surgery is 18, but for minors, informed consent protocols based on WPATH criteria may be applied.187

United States

Some states restrict minors’ access to sex reassignment surgery, while lawmakers in other states are considering it. The World Professional Association for Transgender Health (WPATH) issued more liberal guidance in June 2022, which recommends some surgeries be allowed from the age of 15.188 “Gender-affirming” mastectomies have been performed on children as young as 12.189

Western and Northern Europe

Belgium	Sex-reassignment surgery is not performed before age 18.190 Parental consent is not a factor since surgery is not performed on individuals under the age of consent.
Denmark	In rare cases, breast surgery can be performed before age 18. No other forms of reassignment surgery can be offered to those under 18.191
Finland	Sex reassignment surgery is not performed before age 18.192 Parental consent is not a factor since surgery is not performed on individuals under the age of consent.
France	Mastectomy is theoretically possible from age 14 but is generally performed after age 16.193 Without parental consent, surgery is not available until age 18.
Germany	Sex reassignment surgery is not performed before age 18.194 Parental consent is not a factor since surgery is not performed on individuals under the age of consent.
Iceland	Sex reassignment surgery is not performed before age 16.195 Parental consent is not a factor since surgery is not performed on individuals under the age of consent.
Ireland	Sex-reassignment surgery is not performed before age 16.196 Parental consent is required for those age 16 or 17.
Luxembourg	Sex-reassignment surgery is not available before age 18. Parental consent is not a factor since surgery is not performed on individuals under the age of consent.197
Netherlands	Mastectomies are available from age 16, and all other procedures from age 18. Parental consent is not a factor since surgery is not performed on individuals under the age of consent.198
Norway	Mastectomies are performed from age 16 in “special cases.”199 All other procedures are unavailable until age 18.
Sweden	Sex reassignment surgery is not performed before age 18. Parental consent is not a factor since surgery is not performed on individuals under the age of consent.200
United Kingdom	Sex reassignment surgery is not performed before age 18. Parental consent is not a factor since surgery is not performed on individuals under the age of consent.201

8. Number of youth gender clinics

CONTEXT: Some jurisdictions relegate the assessment and treatment of minors with gender dysphoria to a handful of clinics or even one. These clinics are not immune to problems – the lone pediatric gender clinic in the United Kingdom is being shuttered because of unsafe practices – but centralizing care has the benefit of greater oversight and accountability.

North America

Canada202
Alberta	There are two youth gender clinics in the province.
British Columbia	There is one youth gender clinic in the province.
Manitoba	There is one youth gender clinic in the province.
New Brunswick	There are no youth gender clinics in the province.
Newfoundland & Labrador	There are no youth gender clinics in the province.
Nova Scotia	There is one youth gender clinic in the province.
Ontario	There are four youth gender clinics in the province.
Prince Edward Island	There are no youth gender clinics in the province.
Quebec	There is one youth gender clinic in the province.
Saskatchewan	There are no youth gender clinics in the province.

United States

There are 65 youth gender clinics in the country as of November 2022.203

Western and Northern Europe

Belgium	The country has are four gender clinics.204
Denmark	Hormone therapy is administered to individuals of any age at one of three locations. These clinics are responsible for assessment and coordination of treatment.205
Finland	The assessment and treatment for individuals with gender dysphoria of all ages is administered through two hospitals.206
France	Care is decentralized. Any doctor can prescribe treatment for medical transition.207
Germany	There are 15 clinics and hospitals that provide gender-affirming care of one kind or another.208
Iceland	The assessment and treatment for minors with gender dysphoria is administered through one hospital.209
Ireland	The assessment and treatment for individuals of all ages with gender dysphoria is administered through one hospital.210
Luxembourg	There is one gender clinic in the country, though treatment is more commonly sought abroad.211
Netherlands	One clinic provides sex reassignment interventions to 95 percent of the population.212
Norway	Assessment and treatment for individuals of all ages with gender dysphoria is administered through one hospital.213
Sweden	Assessment and treatment for individuals of all ages with gender dysphoria is administered at seven different locations.214
United Kingdom	Pediatric gender services are limited to clinical research settings. It is unclear how many such settings there are.215

9. Notable changes in protocols for treating minors

CONTEXT: The concern that children are too quickly referred for gender-affirming medical treatment has arisen in several European countries. Given questions about the wisdom and judgement of children to make life-altering and permanent decisions about their health, officials have revised policies and guidance about gender-affirming care.

North America

Canada	Recent changes in Saskatchewan require young students to get parental consent to change their pronouns in school.216 Alberta recently announced major restrictions on hormone therapy and surgeries for minors.217
United States	As of June 2024, 25 states have enacted laws to significantly limit (and in some cases ban) “gender-affirming care” for minors.218

Western and Northern Europe

Country	Notable changes in protocols for treating minors
Belgium	No changes have been formalized, but doctors involved with treating gender distressed minors are publicly urging authorities to follow the lead of other European countries (e.g. the UK, Finland, and Sweden) that are now taking a more cautious approach.219
Denmark	In 2023, an article published in the Journal of the Danish Medical Association confirmed that Denmark has “adopted a more cautious approach to hormone therapy until more evidence of its beneficial effects is available.” Hormonal intervention is now limited to exceptional cases in minors.220
Finland	In 2020, the Finnish Health Authority “deviated from WPATH’s “Standards of Care 7” by issuing new guidelines that state that psychotherapy rather than puberty blockers and cross-sex hormones, should be the first-line treatment for gender-dysphoric youth. This change occurred following a systematic review of evidence, which found the body of evidence for pediatric transition inconclusive.”221
France	In 2022 the National Academy of Medicine warned about the influence of social contagion vis-à-vis trans identity among youth and adolescents and urged “great caution” in treatment.222 No changes have been formalized.
Germany	In 2024, the German Medical Assembly passed a resolution to restrict access to hormone treatment and self-determination of gender ID to those over 18.223 At nearly the same time, German legislators passed the Self-Determination Act giving those 14 and older the ability to change their name and gender via the civil register (with parental consent).224
Iceland	No changes.
Ireland	No changes have been formalized, but the adult national gender service is urging the Department of Health to drop its support for the World Professional Association for Transgender Health (WPATH) model, noting that a “significant number” of patients who have graduated from the youth to the adult gender service are autistic and exhibit “unclear gender identity.”225
Luxembourg	No changes.
Netherlands	A commentary published in the Dutch Journal of Medicine in 2023 acknowledges that children now receiving hormonal intervention have different profiles overall (e.g., more autism, dysphoria emerging in adolescence rather than childhood) from the cohort of children for which the “Dutch protocol” of care was developed. It recommends that the Netherlands should “immediately radically reform gender care, following the example of Sweden and Finland.”226 No changes have been formalized.
Norway	In 2023 the Norwegian Health Care Investigation Board characterized pediatric gender medicine as “experimental” and recommended a more cautious approach toward pediatric transition. The Norwegian Directorate of Health has not yet adopted the board’s recommendation.227
Sweden	In December 2022 the Swedish National Board of Health and Welfare published updated guidance that urges greater caution in administering hormonal treatments or sex reassignment surgeries to minors. Such treatments should only be administered to minors in “exceptional” cases and must be tracked for research purposes. Insufficient evidence, an unexplained increase in dysphoria diagnosis among girls ages 13 to 17, and occurrences of “detransition” (i.e., trying to undo the changes) are specifically cited as reasons for greater caution.228
United Kingdom	An official review from the former president of the Royal College of Paediatrics and Child Health deemed the Tavistock Youth Gender Clinic “not a safe or viable long-term option” for children. The National Health Service has begun to implement several notable changes, including: closing the Tavistock Youth Gender Clinic; repudiating the affirmation model in favour of one that treats claims of dysphoria with greater skepticism and uses psychotherapy as the first intervention; discouraging the use of social transition in prepubescent children; clarifying that a true multidisciplinary team is comprised not only of “‘gender dysphoria specialists,’ but also of experts in pediatrics, autism, neurodisability and mental health, to enable holistic support and appropriate care for gender dysphoric youth.”229 On March 12, 2024, the UK banned puberty blockers for minors younger than 18.230

Conclusion

In Canada and the United States, much younger patients are eligible for invasive surgeries and/or potentially irreversible and medically harmful dispensation of puberty blockers and cross-sex hormones, than is the case in Europe. Overall, Canada and the United States are the most permissive countries when it comes to the legal and medical gender transition of children.

Given the growing body of evidence and the emerging European consensus, which is grounded in medical science and common sense, Canada and the United States should protect our youngest and most vulnerable patients by reconsidering the gender-affirming model of care.

Endnotes

Please see references in PDF

About the authors

Roy Eappen, MDCM, FACE, FRCP(C). FACP, CD, is a practicing endocrinologist in Montreal, assistant professor of medicine at McGill University, and a senior fellow at both Do No Harm and the Aristotle Foundation for Public Policy.

J. Edward Les, MD, is a practicing pediatrician in Calgary and a senior fellow at the Aristotle Foundation for Public Policy.

Ian Kingsbury, PhD, is director of research at Do No Harm.

Acknowledgements

The authors would like to thank and publicly acknowledge Danny Randell and Matin Koohkan for their considerable contributions as research assistants.

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