Trans Health Care

Referral

Trans health care, or gender affirming health care, might for example include hormone treatment and surgery. All treatments are optional. The health care is accessible for persons experiencing gender dysphoria, meaning both for transmen, transwomen and non-binary people. To get access to this health care you need a referral to a gender assessment team. There are teams in seven locations in Sweden. The teams have different rules for who can write the referral, but many of them want the referral to be written by a psychiatrist. You can therefore contact a psychiatric unit where you live and ask them to write a referral. The person making the referral doesn’t make an assessment and you don’t have to meet certain criteria to get a referral. Sometimes you have to get a referral to the psychiatrist from your GP (“vårdcentral”) as a first step. Youth clinics and BUP can help with referrals to teams that take on patients who are 18 or under.

Disabilities and earlier diagnoses shouldn’t stand in the way of you getting a referral.

At the teams in Alingsås (Lundströmmottagningen), ANOVA in Stockholm, and Linköping you yourself can submit your own referral. However, if you live in another part of Sweden and want your expenses for travel covered to and from the team, you need a referral from someone within the Swedish healthcare system.

If you aren’t a resident in Sweden, the teams might not accept your referral. Gender affirming health care is frustratingly enough not considered as something asylum seeking persons can have access to. The exceptions are: if you are under 18, or if you have an ongoing hormone replacement therapy.

Waiting times can be long after writing the referral: it might take up to 2 years before you have your first meeting with the team.

Assessment and diagnosis

The team usually consists of a doctor, a counselor and a psychologist. The assessment itself consists of sessions where you talk about how you view your own gender identity. You also get to fill out different valuation scales and other forms. Most people get a diagnosis after about a year, but it can be quicker or take longer.

The aim of the assessment is to see if you experience gender dysphoria, meaning discomfort or suffering because of you gender identity doesn’t match the gender you’ve been assigned. If so, there are three different diagnoses that are possible. All three diagnoses give you the possibility to hormone treatment and top surgery, but in order to be able to change your legal gender and have genital surgery you have to have the diagnosis called “transsexualism”.

The fact that it is a diagnosis doesn’t mean that you’re sick, but that you need health care. The aim of the care is to lessen the gender dysphoria and improve your wellbeing.

When you’ve gotten the diagnosis you will keep seeing the assessment team for a while at the same time as treatment is started. This time is sometimes called ”real life experience”, and if you haven’t lived according to your gender identity you usually start now. That means coming out to those around you about your gender identity. This is mainly for persons who have the “transsexualism” diagnosis.

Common treatments

Depending on your health and wishes you can get a number of different treatments and surgeries. No form of treatment is mandatory. Everyone can, together with the assessment team and other doctors, decide what suits them. In principal the whole treatment is covered by the high-cost protection for medications and doctor’s visits. For non-binary persons younger than 18 years, the health care is limited.

Hormone treatment

Hormone treatment is either given in the form of testosterone or oestrogen. In healthcare testosterone is usually called “masculinizing hormone treatment” and oestrogen “feminizing hormone treatment”, but all bodies produce both these hormones. The effects of the treatment is comparable to puberty. Some parts of the body aren’t affected by the treatment. If you stop taking hormones some changes will be reversed while others are permanent. If you want to keep all the effects, hormone treatment is therefore life long.

Testosterone is usually either given as a shot every ten to twelve weeks or as a gel that is applied to the body every day. The shot is often given at a health centre. With testosterone treatment you will most likely get a darker voice, facial hair, greater muscle mass and an increase in bodily hair. Bleedings (menstruation) ceases, which means it’s hard (but not impossible) to get pregnant as long as you’re under treatment.

Oestrogen is mainly given as pills, gel, or patches. If you have testicles (even though that might not be the preferred word to use), you usually get pills that make the body produce less testosterone. If you take oestrogen you usually get more subcutaneous fat, smaller muscle mass, softer skin, and growth of the breasts. Hair loss on the head usually ceases. The ability to get an erection decreases, but if this is a problem for you, you can talk with the doctor prescribing it and see what can be done.

There are differences in how people react to hormones. It depends on your genes but also on your health and age. The effects cannot be predicted. It also differs between people how long it takes to get the maximum effect of the hormones.

Persons under the age of 18 can get so called puberty blockers to keep the body from continuing a puberty that doesn’t correspond with one’s gender identity. When you stop taking stop puberty blockers, the body’s own puberty will start again, or you can (depending on your age) start treatment with the desired hormones instead.

In Sweden hormone treatment is given through the publicly funded health care and you need a gender dysphoria diagnosis to access hormone treatment. The person undergoing hormone treatment has regular check-ups and the dose is adjusted individually. Some people self medicate with hormones. Since hormones can affect the body in different ways (for example blood count and liver function) there are risks associated with taking hormones outside of healthcare. Persons who take hormones without consulting healthcare should therefore be aware of the risks.

Top surgery

Testosterone doesn’t make the breasts (even though that might not be the preferred word to use) disappear, unwanted breasts have to be surgically removed. This operation is called mastectomy. Often several operations are needed to get the desired result. A person treated with oestrogen often develop breasts, but there’s an opportunity to surgically enhance the breasts using implants. Public health care usually waits at least a year after hormone treatment has started in order to see how much the breasts grow from the treatment and will only after that complement with implants, if needed.

There are different methods for top surgery. The method is decided by the surgeon together with the person who is having the operation. Factors that influence the decision are, among other things, the body’s prerequisites but also the desired result. When it comes to mastectomy some people prefer to have multiple operations in order to get the least amount of scar tissue. Others would rather undergo one big operation to get a flat chest as soon as possible. In breast augmentations the surgeon has guidelines when it comes to the size of the implants. Most implants have to be changed later in life.

There’s also the opportunity to undergo top surgery without a diagnosis, at a private clinic. The operation then has to be funded by you.

Bottom surgery

Bottom surgery is available today for people who have gotten the diagnosis transsexualism, have been in contact with a gender assessment team for at least 2 years, and are at least 18 years old. You need a permit from the National Board of Health and Welfare in order to have bottom surgery. This permit can be applied for with the help of the gender assessment team. There is no demand for bottom surgery when changing legal gender.

There are different kinds of operations of the genitals. You can create a vagina, clitoris and labia from a penis and scrotum (even though those might not be the preferred words to use). It’s often done in steps through multiple surgeries. After the operation you need to dilate (train with a rod) regularly if you want the vagina to keep its shape and size. Lubricants may be needed during sex.

Clitoris (even though that might not be the preferred word to use) usually grows during testosterone treatment, and this body part can be used to create a smaller penis. Another alternative is creating a larger penis by taking tissue and skin from another part of the body, for example the groin, underarm or thigh. There are several different methods and a scrotum can also be created. What type of surgery is best, and whether you leave the vagina, uterus and ovaries (even though those might not be the preferred words to use), is decided together with a doctor. Some people choose a penis prosthesis instead of a created penis.

Persons keeping the vagina but also have changed to a male social security numbers won’t be getting a summons for gynecological pap smears. You must then make the appointments yourself. The recommendations are to go every three years.

Testosterone treatment can lead to brittle mucous membranes. There can be a need for applying extra lubrication in the form of lubricants.

Oestrogen treatment is believed to reduce the risk of prostate cancer somewhat, but it’s unclear to what extent. There are no summons for testing, both the healthcare and the patient can raise the issue. Factors that influence the need is heredity, age and symptoms. Those born with a prostate (even though that might not be the preferred word to use) and have changed to a female social security number are recommended to tell the healthcare staff that they have a prostate.

Speech therapy, hair removal and other care

Apart from hormone treatment, top surgery and bottom surgery healthcare offers some other care, for example sessions with a speech therapist. Speech therapists are specialized in voice and communication. Oestrogen doesn’t affect the voice. Instead you can get help from the speech therapist to find a pitch that feels comfortable. Those who start testosterone treatment enters into puberty voice change and the voice develops for at least a year. In this case the speech therapist can also be a support in finding a comfortable pitch.

Oestrogen treatment has a very small effect on facial hair and other bodily hair. Hair removal is therefore offered through the public health care system. What methods that are offered differs between the county counsels. The methods differ depending on the colour of the hair and the skin. It’s often removal of facial hair and hair on parts of the upper body that are covered by the public health care.

Other care that might be needed is vocal chord surgery and a reduction of the larynx. Liposuction of the hips and feminizing facial surgery are currently not offered as treatments in Sweden.

Fertility preserving treatment and pregnancy

Many of the treatments and surgeries can get lead to you not being able to get pregnant or make someone pregnant. Therefore, there are different forms of fertility preserving treatments to make it easier to get biological children if or when you want to.

People with testicles (even though that might not be the preferred word to use) can get help freezing sperm in order to have the possibility to become a biological parent in the future. This is most easily done before you start hormone treatment or during a break in the treatment. The sperm can later be used for insemination or in vitro fertilization, together with an egg from the partner, co-parent or surrogate. Surrogacy is currently not allowed in Sweden.

People with ovaries (even though that might not be the preferred word to use) can get help freezing and saving eggs or embryos (fertilized eggs) that you can later use to get pregnant yourself or make a partner or co-parent pregnant. Outside of Sweden, surrogacy might be relevant. To harvest eggs you have to take a break in, or postpone, testosterone treatment and instead take hormones to make as many eggs as possible mature at the same time. It’s also possible to freeze ovarian tissue.

A person born with ovaries who wants to get pregnant needs to take a break in the testosterone treatment before and during a pregnancy. It varies between individuals when the period comes back. There’s not enough data in order to be able to conclude if hormone treatment with testosterone affects the ability to get pregnant, but many who take a break in their hormone treatment are successful in getting pregnant.

Read more about assisted reproduction and feritility preserving treatment.

Name change

You yourself can at any time choose to change your name if you are over 18. The same goes for those under 18, as long as your legal guardian approves of the name change.

You apply at the Swedish Tax Agency. You can choose or mix traditional female names, traditional male names or gender neutral names, regardless of your gender identity or legal gender. You can add namnes to your present legal name or change your name(s) altogether.

Changing legal gender

In order to change legal gender (legal gender recognition) and get a new social security number you need to be at least 18 and nationally registered in Sweden. You need a testimonial from a gender dysphoria assessment that verifies that you as an applicant are living in accordance with another gender than your current legal gender and that you are expected to live in accordance with this gender in the future. You need a “transsexualism” diagnosis and need to have had contact with a gender assessment team for at least 2 years. The gender assessment team can help you write the application to the legal council. The application is sent to the National Board of Health and Welfare’s legal council, where the decision is made. They in turn inform the Swedish Tax Agency who changes the social security number.

Also, it is the National Board of Health and Welfare’s legal council that gives a permission for you to have bottom surgery. Most people apply for this at the same time as applying for a new legal gender. But you don’t need to undergo genital surgery in order to change your legal gender.

Read more about trans care at RFSL Ungdom’s and RFSL’s website Transformering (only in Swedish)

The National Board of Health and Welfare’s advice for you who want trans care (pdf)

The Public Health Agency of Sweden’s report Hälsan och hälsans bestämningsfaktorer för transpersoner – En rapport om hälsoläget bland transpersoner i Sverige

The National Board of Health and Welfare’s knowledge support God vård av vuxna med könsdysfori

The National Board of Health and Welfare’s knowledge support God vård av barn och ungdomar med könsdysfori