Treatment of young people with gender incongruence requires more than consent

Everyone wants to help children who struggle with gender identity. But health care must be based on knowledge, not merely good intentions.

By Mikael Scott Bjerkeli - Executive Director, Harry Benjamin Resource Centre

Health care services for children and young people with gender incongruence have received increased attention in recent years, both in public debate and within the health sector. It is an important step forward that these children and young people are seen and listened to. At the same time, society has a responsibility to ensure that the care offered is safe, evidence-based, and ethically well considered.

In this debate, concepts such as “the right to treatment” and “informed consent” are used frequently, often without sufficient clarification of what they actually mean in medical and legal terms. It is high time that we addressed this.

Not everything can be self-determined

Many people understand the concept of “informed consent” to mean that children and young people should be able to choose medical treatment provided they have received relevant information. In practice, however—and particularly in health care for minors—consent involves far more than this. It concerns maturity, comprehension, assessment of risk, and documentation demonstrating that the patient has actually understood both what is being offered and what remains uncertain.

Health care professionals have an independent responsibility to ensure that treatment decisions are clinically sound. This requires consideration of mental health, identity development, social influences, and comorbidities before offering medical interventions with irreversible or long-term consequences. This responsibility applies regardless of how motivated the patient may be.

Recent national data from Norway indicate that over 60 per cent of minors referred for gender incongruence have at least one pre-existing psychiatric condition. More than one third have a history of self-harm. This means that many of those seeking help are navigating demanding and complex life circumstances. We owe it to them to consider their situation as a whole, rather than limiting our response to affirmation alone.

The guidelines lack clear direction for clinical practice

The current national clinical guideline for gender incongruence provides little concrete guidance on how clinicians should approach patients in practice. While it outlines rights and overarching principles, it says relatively little about how assessment, clinical judgement, and follow-up should be carried out.

There is therefore a need for professional guidelines that clearly describe how health care professionals are expected to work clinically, including requirements for assessment, documentation, and professional accountability. Without such guidance, we risk inconsistent practice, weakened patient safety, and poorer quality of care.

Consensus alone is not a guarantee of quality

International guidelines, including those developed in Germany, have recently been highlighted as models to follow. It has been claimed that the German guideline adopted in 2025 is thorough and aligned with other forms of health care for minors. However, this does not present the full picture.

Several professionals and organizations withdrew from the development process in protest. They argued that the process failed to adequately address the limited clinical evidence base and weakened the principle of psychiatric assessment. The document that was ultimately adopted is a so-called S2k guideline—that is, a consensus-based document rather than a systematic, evidence-based guideline. As a result, its scientific quality does not meet the standards normally required for medical practice.

When such guidelines are promoted without acknowledging this professional disagreement and criticism of the process, an impression of broad professional consensus is created where none exists. We must be willing to demand methodological rigor and transparency, including in areas that are politically or socially sensitive.

The best interests of the child require more than affirmation

“The best interests of the child” is a strong and central principle in Norwegian legislation. In discussions of gender incongruence, however, a misconception often arises that this principle simply means giving the child what they want, without further consideration. This is incorrect.

The best interests of the child involve safeguarding the child as a whole, including their future and their safety. This requires careful consideration of risk, development, comprehension, and which forms of treatment are genuinely in the child’s long-term interests. In other areas of the health service—such as ADHD treatment, surgical interventions, or mental health care—it is taken for granted that such decisions are made through thorough, interdisciplinary assessment. The same must apply here.

Providing health care to children and young people with gender incongruence is not the same as simply affirming a diagnosis the patient has arrived at themselves. It is a professional responsibility and must be treated as such.

What needs to be done?

We need safer health care, not faster health care. This includes:

• Revising national clinical guidelines so that they are based on systematic reviews of the clinical evidence
• Making psychiatric and psychological assessment a mandatory component of the clinical pathway
• Understanding informed consent as an ongoing process, not a procedural formality
• Establishing a national registry to support follow-up and quality assurance of treatment pathways

Children and young people have a right to be taken seriously—not only in how they express themselves, but also in their vulnerability. It is our responsibility to meet them with more than good intentions. We must meet them with professionalism, patience, and respect for complexity.

Click here to read the original article in Norwegian.