Many trans people need health care and treatment in order for the body to better correspond to the gender identity and who they are as a person. For many it's vital to get the this health care, while others don't want any special care or treatment.
Trans health care, or gender affirming health care, comprises for example hormone treatment and surgery. The health care is accessible for persons with gender dysphoria, meaning both for transsexuals and non-binary people. To get access to this health care you need a referral to a gender assessment team. There are teams in six locations in Sweden. The teams have different rules for who can write the referral, but most 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. Youth clinics and 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.
Assessment and diagnosis
The team usually consists of a doctor, 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 their diagnosis after about a year, but it can be quicker or take longer.
The diagnosis you can get is gender dysphoria and there are three versions of the diagnosis. All diagnoses gives the right to hormone treatment and top surgery, but in order to be able to change the legal gender and have genital surgery you have to have the diagnosis “transsexualism”. The diagnosis doesn’t mean that you’re sick, but that you need care. The aim of the care is to lessen the gender dysphoria so that you can feel better.
When you’ve gotten the diagnosis you 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.
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 very limited.
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”. The effects of the treatments 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. Those who 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 given as pills, gel, patches or as a shot every two to four weeks. 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.
There are big 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.
Children who haven’t yet entered puberty can get so called stop hormones to keep the body from entering into a puberty that doesn’t correspond with their gender identity. When you stop taking stop hormones puberty starts up again, or you can start treatment with the desired hormones instead.
In Sweden hormone treatment is given through the county council 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 choose to 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.
Testosterone doesn’t make the breasts 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. The county council 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.
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 is, 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, but the operation then has to be funded by you.
Bottom surgery is available today for people who have gotten the diagnosis transsexual and is 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. It’s often done in steps through multiple surgeries. After the operation you need to train with a rod regularly in order for the vagina to keep its shape and size. Lubricants may be needed during sex.
Clitoris 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, is decided together with a doctor. Some people choose a penis prosthesis instead of a created penis.
Those who keep their vagina but 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 and have changed to a female social security number are recommended to tell the healthcare staff that they have a prostate.
Speech therapist, 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 county council. What methods that are offered differs between the county counsels. The methods differ depending on the colour of the hair. It’s often removal of facial hair and hair on parts of the upper body that are covered by the county council.
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 only granted in exceptional cases.
Fertility preserving treatment and pregnancy
Many of the treatments and surgeries trans people can get lead to you not being able to get pregnant or produce sperm. 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 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, if/when it is allowed in Sweden.
People with ovaries can get help freezing and saving eggs or embryos (fertilized eggs) that you can later use to get pregnant yourself or, if/when it’s allowed in Sweden, make a partner, co-parent or surrogate pregnant. 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.
You can read more about different options here: http://www.hbtqfamiljer.se/
You yourself can at any time choose to change, add or remove your whole, or parts of, your name if you are over 18. The same goes for those under 18, as long as their legal guardian approves of the name change.
The first time you want to change your name you can apply at the Swedish Tax Agency, as long as you keep at least one of your first names. If you want to change all of your first names you have to go to the Swedish Patent and Registration Office. You can choose or mix traditional female names, traditional male names or gender neutral names, regardless of your gender identity or legal gender.
Changing legal gender
In order to change legal gender 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. 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. Today a permission is needed from the legal council in order to have bottom surgery. The gender assessment team can help you write the application to the legal council.
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