Response to interpellation 2022/23:13 on urgent reforms for trans and intersex people
Translated from Swedish by AI; the translation may contain errors. The Swedish text is the original.
Summary AI, written in advance
1 KD argues that the current referral to the Council on Legislation implies more self-determination than current legislation 1. KD considers that surgical interventions should not require permission from the National Board of Health and Welfare but should be preceded by an investigation 1. KD argues that the National Board of Health and Welfare leads the work on national highly specialized care and that the government follows their reports 1. KD considers that the waiting times are deplorable and that an improved working environment is necessary to shorten the waiting times 2. MP argues that the current referral to the Council on Legislation does not meet the requirements for self-determination as the draft based on self-determination has been removed. 3 MP argues that irreversible surgical interventions on small children with intersex variations may be in conflict with the Patient Safety Act 3. 3 MP argues that the current proposal for a gender identity law does not provide sufficient self-determination because an application still has to be reviewed 3. 4 MP requests a national highly specialized care to ensure quality and shorten waiting times 4. 5 KD confirms that the previous government considered risks of abuse of the law 5. 5 KD argues that parents do their best for their children and that medical assessment is central 5. 6 KD emphasizes the importance of following up on highly specialized care and knowledge management 6.
Written by AI in advance and may contain errors. The numbers lead to the speech a statement builds on; check against the text below.
Statsrådet Acko Ankarberg Johansson (KD)
Madam Speaker! Ulrika Westerlund has asked me how the government is working to establish a new gender identity law that meets the requirements for self-determination. Furthermore, Ulrika Westerlund has asked me how the government follows up on the Socialstyrelsen's work to make the care national highly specialized care. The interpellator has also asked if there are plans for other measures to secure access to care within a reasonable time and not risk further increasing the mental ill-health of people waiting for care. Finally, Ulrika Westerlund has asked me if there are any plans to investigate a ban on medically unnecessary interventions on persons with intersex variations who have not consented to the interventions.
Madam Speaker! The work to establish a new gender identity law that meets the requirements for self-determination to a greater extent than the current legislation has come far. The previous government decided in July 2022 on the referral to the Council on Legislation for Improved opportunities to change gender. In the referral to the Council on Legislation, it is proposed that two new laws - the Act on certain surgical interventions on the genitals and the Act on changing the gender appearing in the population register - shall replace the Act on establishing gender identity in certain cases. Follow-up changes in other laws are also proposed. The proposals mean that the process for changing the gender appearing in the population register is separated from the process for surgical interventions on the genitals.
No permit from Socialstyrelsen shall be required to undergo such surgical procedures on the genitals as aim for the person's body to correspond with the gender identity. Such procedures shall, however, in the same manner as under the current order, be preceded by an investigation within healthcare and may be performed on persons who have reached the age of 18. In the referral to the Council of Legislation, it is also proposed that a person who has reached the age of 16 shall have the gender appearing in the population register changed after a simplified assessment of the gender identity. An application for a child is made by the child's guardian with the child's written consent. An overriding goal is that the procedure for changing the gender appearing in the population register is simplified.
Regarding the issue of national highly specialized care, it is the National Board of Health and Welfare (Socialstyrelsen) that leads the work to concentrate care at a national level. Criteria for assessing the authority's results in the work with highly specialized care are that it shall have a legally secure and efficient as well as a transparent and trust-based work and decision-making process. The National Board of Health and Welfare describes this work annually in its annual report. On its own initiative, the National Board of Health and Welfare has investigated and decided that the care area for gender dysphoria shall become national highly specialized care. The National Board of Health and Welfare follows up on national highly specialized care and publishes new results once a year. The Government takes note of these results.
Access to care and treatment is primarily the responsibility of the regions. As Minister for Health and Social Affairs, I will work to ensure that Sweden's health and medical care is equitable and provided on equal terms for the entire population. According to the Health and Medical Services Act, the goal of health and medical care is good health and care on equal terms for the entire population. Care shall be provided with respect for all people's equal value and for the individual's dignity. Those who have the greatest need for health and medical care shall be given priority to care. Waiting times and care queues in Sweden need to be shortened and accessibility to care improved so that more patients receive care in a timely manner. Accessibility also concerns geographical proximity, opening hours, the use of digital care, and digital solutions for contacts with care.
The government allocates 3 billion kronor annually for the purpose of increasing accessibility and shortening waiting times within health and medical care. During the years 2023-2025, an additional 2 billion kronor per year is invested in more care beds. From next year, the government also invests 100 million kronor annually for a national state care brokerage so that waiting patients can be offered care in another region where capacity exists more quickly. In this way, the entire health and medical care system's total capacity is used more efficiently.
In the report Transpersoner i Sverige - Förslag för stärkt ställning och bättre levnadsvillkor (SOU 2017:92), it was proposed, among other things, that Socialstyrelsen should be given a mandate to develop a knowledge base for the healthcare field. Socialstyrelsen has subsequently, on behalf of the government, developed a knowledge base for the healthcare professions regarding care and treatment for intersex conditions. The results from the report have been guiding in the development of the knowledge base.
The knowledge support is primarily aimed at healthcare professionals who encounter individuals with DSD, differences in sex development, in their work, either regularly within the specialized teams or more rarely within primary care. Since DSD and variations in sex characteristics are unknown to many, it is hoped that the knowledge support will also contribute to increased knowledge among the general public. The Government considers that Socialstyrelsen, in consultation with expertise within the healthcare professions, is best suited to assess which materials are needed.
Both the Health and Medical Services Act and the Patient Act establish that consent is required for all treatment within health and medical care. The treatment shall also be based on a medical need. If there is a need for medical intervention on a child who, due to their young age, cannot consent, the decision is made by the parent or guardian in accordance with Swedish legislation, including the UN Convention on the Rights of the Child. This also applies in the matter of medical interventions on persons born with intersex variations.
Ulrika Westerlund (MP)
Madam Speaker! Thank you for the answer, Minister for Health and Social Affairs! I naturally have some follow-up questions. It is actually three questions in one, one could say. It is three different areas. I will begin with that which concerns the Gender Recognition Act.
In the response, it is said that the referral to the Council on Legislation submitted in August fulfills the requirement for self-determination to a greater extent than the current legislation. I do not quite agree with that. It is a simplified process and a lowered age limit in this proposal – I welcome that. But precisely this part about self-determination has actually been removed. That was the very point of the draft for the referral to the Council on Legislation that was handed over about a year ago. It was both Miljöpartiet and Socialdemokraterna who stood behind this draft. Since then, it has been in the referral process, and now this referral to the Council on Legislation arrived.
I advocate that the government should consider proceeding with the draft for the referral to the Council on Legislation. It was based on a very long process. The first investigation into the matter came in 2014. Since then, this has been sidelined. Several new investigations have been conducted. Departmental reports and other things have been made. Different parts of the legislation have been examined.
It must be possible to move forward now. The draft for the referral to the Council on Legislation is over 200 pages long. It is a very solid investigation where a multitude of different objections have been taken into account, also the objections that came from the Council on Legislation regarding the previous referral in 2018. I therefore advocate that we move forward with this.
In the now proposed legislative text, there are, for example, still – apart from the fact that it is not self-determination but that it shall be an application – arbitrary criteria remaining, for example that it shall be assessed whether someone can be assumed to want to live with a certain gender identity within a foreseeable time. These are not definitions that cannot be interpreted in many different ways. This obviously opens the door for arbitrariness.
Another serious problem is that this will continue to take resources from healthcare, as doctors will have to be involved in the process to assess whether it is de facto in this way. The point of self-determination is, after all, that one should be able to apply independently. The assessment should not be made by anyone else.
Then I move on to gender-affirming care. It is a subject area that has been very much debated for several years. Unfortunately, I believe it has led to an erosion of the care. There are examples of doctors who no longer want to work within the care because they cannot manage and because they work in an underfunded area where they also risk being portrayed as a person who does not want what is best for their patients. There is a lot of debate and attacks on doctors. It is a problem.
This has led to waiting times of between just over 20 months and just over 30 months to get to a first consultation with a psychiatrist. It is a very long waiting time that is not anywhere near what can be judged as reasonable. These waiting times are detailed in a report from the Gender Dysphoria Register that came earlier this year. They have tried to get answers from different clinics and have received them from some.
Then it concerns the national highly specialized care. It was a decision from Socialstyrelsen that I welcomed. The problem is that the decision-making process has since been dragged out. This has created uncertainty for specialist clinics, which now do not know if they will be allowed to be specialist clinics in the future. In that case, they cannot make any investments, and then the waiting times are extended even further.
Now I see that my speaking time is almost over. I will simply return to area three.
Statsrådet Acko Ankarberg Johansson (KD)
Madam Speaker! To the member, I would like to say that I did not manage to finish my entire answer either. Time goes a bit too fast sometimes.
We can start with the questions that Member Ulrika Westerlund raises. It is still the case that there is more self-determination in the latest Government referral to the Council of Legislation than in the existing law. Then, the Member has highlighted the Government referral that was in between. In that case, I understand the point of view, and I listen to what the Member says.
The government is doing as usual. We are processing the views that have been submitted. I cannot say anything about what the upcoming proposal will be, but I am listening to what the member says and will, to the best of my ability, ensure that we move forward.
Not least, this has taken a terrible amount of time - many, many years. I would probably say that the debate has surged back and forth. Sometimes it has moved very quickly in one direction, and then it has moved very quickly in another direction. It is clear that this makes many actors feel uncertain. It can also mean that the person who is a patient is not always met by staff who feel secure in what they are to do. The debate, after all, surges back and forth.
That is why I think that the Socialstyrelsen's work with guidelines and clarity regarding highly specialized care is a good guidance for all staff. When I seek care and want help, I should be able to feel that all staff are well-informed and can provide me with the best care.
However, we have the arrangement that politics does not determine which medical assessments are made, but it is the National Board of Health and Welfare that decides how one works with highly specialized care. We - that is the tedious expression - follow what they report. It is clear that we cannot have opinions on the content of a medical assessment of how one works with the care - I know the member does not request that. But what we can have opinions on is the pace of the work and how one arrives at a good solution. We will surely have to return to these parts when the next report on highly specialized care arrives.
Then I want to add that the Committee on Health and Welfare has previously directed criticism at previous governments for moving a bit too fast with highly specialized care. They have worked in a bit too many areas, and it may have depleted local healthcare when they have not ensured that the acute hospitals have the required competence, while it has become very much highly specialized care. I want to tell the member that I will also look at the issue of highly specialized care from that perspective, so that we use it where that knowledge is needed but not in more areas than necessary. Just that area the member raises is one of the areas where it is important that we have the best competence, so that it can be equal care for all people.
Then there is the matter of the waiting times. It is utterly deplorable. I believe that many have waited a long time before they finally seek care, and when the time finally comes, there are very long waiting times. Unfortunately, it is a situation that these people share with many others. It is a major condition that I and many other healthcare politicians have before us: to ensure that waiting times are shortened, to ensure that one receives the care and treatment one needs, but also to ensure that the working environment is improved. If we do not improve the working environment for the staff, we will not be able to shorten any waiting times.
I would like to conclude by saying that the government will return regarding the law. I cannot comment on it yet, as it is not fully prepared. But I am happy to listen to what Member Ulrika Westerlund says based on the knowledge and experience that the Member has. I will take that with me into the work.
Ulrika Westerlund (MP)
Madam Speaker! I thank you again for the answer. I come back here to that which concerns persons with intersex variations. It has been established that a knowledge support was indeed produced concerning the care of persons with intersex variations. The Equality Ombudsman has looked at the issue of discrimination from an intersex variation perspective - it is therefore about discrimination of persons with intersex variations. And it is written in a report that came earlier this year that the number of surgical interventions on minors has decreased thanks to the knowledge support that came in 2020, but that it is not a total stop.
DO also writes that there is legal-scientific criticism of the procedure - that irreversible surgical interventions are performed on very small children who cannot express any will of their own. This, some legal-scientific critics argue, cannot be said to fulfill the Patient Safety Act's requirements for care based on science and proven experience.
I would therefore like to encourage the government to look again at whether we should consider legislation. Sweden, together with other countries, has been encouraged to legislate, for example by the Council of Europe's Commissioner for Human Rights in 2015 but also in a resolution from the European Parliament in 2019, where the legislation of Malta and Portugal is highlighted as examples that could be followed.
I will go back a bit to the gender identity law and the differences between the draft for the Council on Legislation referral and the Council on Legislation referral. I maintain that it is not that much more self-determining, because the point is that it is still proposed that it should be an application, not that one simply reports that one wishes to change legal gender just as one reports that one wishes to change name. The application shall be reviewed by an external party, which continues to be the Socialstyrelsen's legal council. This removes the very point of self-determination.
In the Council of Legislation referral that arrived in August, some different arguments were presented as to why it landed there. Concerns are raised that the law could be exploited for criminal purposes, in principle that people could exploit the opportunity to easily change legal gender because they then change their personal identity numbers and believe they can hide in the system in various ways. This is an issue that has been up for a very long time, and different referral bodies have had somewhat different views on whether such a risk exists.
I asked the Riksdag's investigation service if they could look at what has happened in Norway and Denmark, where since 2014 and 2016 respectively there have been laws similar to those that were in the draft for the Council of State referral. Their counterparts to the investigation service could not find any examples of this having been exploited for criminal purposes.
However, there are a number of implementation challenges, which have also been discussed in Sweden. Some of them concern the person themselves, for example, how the person should receive their grades with the new changed name and personal identity number. We already have that situation, but there is also such as might be thought to affect other people - for example, if one is allowed to serve a sentence in a facility for women only, if one is granted access to changing rooms, and so on. It has been discussed how this can be done, and I absolutely think that it should be looked into. It can also be solved separately, aside from the legislation.
I think it should be followed up how it has gone in our closest neighboring country, which we often consider to be Norway, which basically took our investigation from 2014 and made it into its own law. We can see how it has gone for them and if it is perhaps something that we could follow. Instead of worrying about things that we think can happen, we can look at how it actually went in Norway, as they have quite a long experience by this point.
Statsrådet Acko Ankarberg Johansson (KD)
Madam Speaker! Thank you, the member, for the supplementary knowledge and experiences!
The Social Affairs Committee received information from the then responsible State Secretary in the spring regarding the work that was underway. Precisely the part concerning other persons than those who have gender dysphoria committing an offense under the law was a large part of the information we received then, so I can confirm that it was a major issue that the previous government considered in the work. The current government will return when we have more, but I thank the member for the comments and thoughts provided.
When it comes to intersex variations, it is a bit unusual that we think Malta has good legislation in the area, but it can happen sometimes. Malta does not always have a legal order in this area that we think is good to use, but let it be. It is still a quite difficult question. My starting point when it comes to small children is that the parents do the very best they can for their child, and then a medical assessment is made of what needs to be done. It is a very difficult situation, I think, that parents face when they receive the best medical competence available. These are difficult questions.
I want to be clear that the government has no proposals in this area, but I am listening to what the member says. It is clear that there is every reason for any government to follow up on what is happening within the area and see what assessments need to be made going forward.
I would like to thank the member for having contributed many good and interesting thoughts to the subject that I need to reflect further on.
Ulrika Westerlund (MP)
Madam Speaker! Thank you for a good discussion, Minister!
Regarding Malta, it is very special. Malta has for a long time ranked at the top in the assessments on the LGBTQI area conducted by the independent civil society organization ILGA Europe. Even within ILGA Europe, it has been discussed whether this is good given that Malta has Europe's worst legislation in other areas such as reproductive rights, women's rights and the possibility of having an abortion, for example. But just here, they have for some reason invested heavily and enacted many new laws that have been judged to be good, not only by the European Parliament and themselves but also by civil society organizations.
I advocate that one looks at the different recommendations and perhaps also at DO's report and their considerations of what would be needed, as well as the legal-scientific criticism that is referred to. It comes from a researcher from Uppsala University named Jameson Garland who has taken a particular interest in people with intersex variations.
I will speak a bit more about healthcare. I am, of course, completely in agreement that politicians should not interfere with exactly how healthcare is designed. What I am looking for is what can be done when the situation is so obviously unsatisfactory. It is a small group of people who are very vulnerable and who suffer from mental ill-health as a result of not receiving a desired healthcare intervention. Healthcare has been depleted for a very long time.
I conducted the 2017 investigation concerning trans people in Sweden, and even then, it was a major issue that the waiting times were so long. It has been five years, and since then, it has only become worse. Various measures have been taken. I believe that a national highly specialized care in this area is good because it ensures good quality and equality across the country, but the decision must come now so that we do not further hinder the process for the various clinics that now do not know what will happen for their specific clinic going forward.
Could some small dialogue with Socialstyrelsen about how this is going perhaps be in question?
Statsrådet Acko Ankarberg Johansson (KD)
Madam Speaker! I would like to once again thank the member for kind thoughts and a good conversation.
Of course, we constantly listen to the National Board of Health and Welfare in all matters they are responsible for, not least when it comes to following up on highly specialized care.
Based on what I mentioned, it is quite obvious that we need to gather competence to ensure that people receive the best care and the latest knowledge, and that it is done in the best way when they go somewhere with a need.
Sometimes, however, highly specialized care can mean that other parts of society are depleted. Therefore, it is important that what one commits to is weighed. Now, Socialstyrelsen has decided that it shall do so in precisely this area, and then it is important that it leads to decisions. Even more important is that one then follows up that it becomes so, and I already have a discussion with Socialstyrelsen about that we need to follow up on the knowledge management we have.
We have a tendency to make decisions regarding our highly specialized care and about national guidelines of various kinds, but we have no way of following up to ensure that it actually happens. Every patient must know that if we have said that someone has the best care or that the care should look a certain way, we also follow up to ensure that it does.
I take away several points. It concerns the importance of completing the highly specialized care so that one reaches a conclusion and knows what applies. I also take away what I myself have raised, namely that we must follow up so that patients continue to have high trust in the care, so that it does not happen that we promise something and then nothing happens.
An important issue for me to return to will be that knowledge management becomes real and that it reaches the entire country and the entire population.
Source: The Swedish Parliament. The speeches come from the open data of the Riksdag, translated into English by AI, which may contain errors.