Sweden: Karolinska, SBU and the 2022 guidelines

Why did Sweden's Karolinska hospital stop hormonal treatment of minors in 2021 and what did the national board decide in 2022?

Sweden’s change was not the result of a new Act of Parliament banning medical transition for minors. It was a sequence of clinical and national evidence-policy decisions. The first was local: Astrid Lindgren Children’s Hospital, part of Karolinska University Hospital in Stockholm, altered its practice in spring 2021. The second was national: Socialstyrelsen, Sweden’s National Board of Health and Welfare, revised its recommendations for under-18s in 2022 after commissioning an evidence review from SBU, the Swedish Agency for Health Technology Assessment and Assessment of Social Services.

Background

Sweden’s change was not the result of a new Act of Parliament banning medical transition for minors. It was a sequence of clinical and national evidence-policy decisions. The first was local: Astrid Lindgren Children’s Hospital, part of Karolinska University Hospital in Stockholm, altered its practice in spring 2021. The second was national: Socialstyrelsen, Sweden’s National Board of Health and Welfare, revised its recommendations for under-18s in 2022 after commissioning an evidence review from SBU, the Swedish Agency for Health Technology Assessment and Assessment of Social Services.

These decisions mattered because Sweden had been regarded as an early adopter of specialist gender-dysphoria services for young people. The Stockholm KID team opened in 2000. Yet the population presenting to services had changed substantially. SBU’s 2019 literature inventory recorded a marked increase in Swedish children and adolescents seeking care for gender dysphoria, while finding no scientific studies explaining that rise. Socialstyrelsen later highlighted the increase, especially among 13- to 17-year-olds registered female at birth, as one reason for greater caution (SBU, 2019; Socialstyrelsen, 2022).

The Swedish documents use the terms “puberty-suppressing treatment”, generally GnRH analogues, and “gender-affirming hormone treatment”, meaning oestrogen or testosterone. This dossier retains those terms when describing official policy. The central issue was not whether distressed young people should receive care. Both Karolinska and Socialstyrelsen stated that they should receive assessment, mental-health care and psychosocial support. The dispute concerned whether uncertain evidence justified starting interventions with potentially lasting consequences in minors.

What the documents say

Karolinska’s 2021 policy

Karolinska’s policy document, case reference K2021-3343 and signed by Fredrika Gauffin and Svante Norgren, identified several grounds for its decision. It referred to SBU’s 2019 finding of weak knowledge about long-term consequences, to concerns about the rapid rise in referrals, and to potential risks described in the clinical literature. It also referred to the December 2020 High Court judgment in Bell v Tavistock in England and Wales, particularly its discussion of the difficulty of informed consent for young people facing a treatment pathway with uncertain long-term effects.

On that basis, Karolinska invoked the precautionary principle. It decided that puberty blockers and cross-sex hormones would not be initiated in patients below 16. For patients aged 16 to 18, treatment could occur only in a clinical trial approved by Sweden’s Ethical Review Authority, following full information about potential risks and an assessment of the young person’s maturity and capacity to consent. Existing patients were not automatically withdrawn: clinicians were instructed to conduct an individual review of whether treatment should continue or stop (Karolinska, 2021).

The British legal reference needs careful qualification. The Court of Appeal allowed Tavistock’s appeal on 17 September 2021 in Bell and another v Tavistock, overturning the earlier declaration. Karolinska’s March 2021 decision therefore cited a judgment that was no longer authoritative later that year. That does not erase the hospital’s independent evidence and precaution rationale, but it does mean that the English case should not be presented as a continuing legal basis for Swedish policy.

SBU’s 2022 assessment

On 22 February 2022, SBU published report 342, Hormone treatment of children and adolescents with gender dysphoria. It was a systematic assessment commissioned as input to Socialstyrelsen’s updated guidance. Its conclusion was direct: the scientific evidence was insufficient to assess the effects of puberty blockers or cross-sex hormones on gender dysphoria, psychosocial circumstances, cognitive function, anthropometric measures, body composition or metabolism in children and adolescents with gender dysphoria.

SBU found limited, low-certainty evidence that puberty suppression slows the bone accrual expected during subsequent puberty, while bone density already achieved at treatment commencement is maintained. It reported no randomised trials and called for longer follow-up, including of young people who stop blockers without proceeding to cross-sex hormones, and for better Swedish data from referral through diagnosis and outcomes (SBU, 2022).

Socialstyrelsen’s 2022 decision

Socialstyrelsen’s 2022 position is often inaccurately reduced to either “Sweden banned treatment” or “nothing changed”. Neither description is correct. The Board made its updated recommendations on hormonal treatment public on 22 February 2022, then released the completed national knowledge support, Care of children and adolescents with gender dysphoria, on 16 December 2022.

The Board said that, at group level, the risks of puberty blockers and gender-affirming hormonal treatment were likely to outweigh expected benefits. It identified insufficient evidence on benefit, risk and long-term effects; an unexplained shift in the patient population; documented medical detransition of young adults, with unknown prevalence; and less uniform clinical experience among participating experts than in 2015. It therefore changed the earlier approach from “should” offer to treatment primarily within research. Outside a study, blockers or cross-sex hormones could be used only in exceptional cases under specified criteria (Socialstyrelsen, 2022).

Those criteria included gender incongruence present from childhood, a gender identity stable over time, clear distress caused by pubertal onset, fulfilment of DSM-5 diagnostic criteria, and no circumstances that make clinical assessment unreliable. The guidance also called for careful attention to mental-health conditions, neurodevelopmental issues, trauma, substance use and the young person’s wider psychosocial situation. It stated that psychosocial support enabling a young person to live through endogenous puberty without medication should be the first-line option when selecting care.

The positions

Supporters of the Swedish approach argue that it restores ordinary standards of paediatric evidence and informed consent. They point to SBU’s finding that meaningful benefits remain unproven, to uncertainty about long-term outcomes, and to the irreversible or potentially fertility-affecting implications of later stages of medicalisation. On this view, research protocols, rigorous assessment and non-medical support are ethically required before exposing minors to interventions whose net benefit has not been established.

Critics argue that restricting access can intensify dysphoria and distress, especially during unwanted puberty, and that the absence of randomised trials does not demonstrate absence of benefit. They contend that carefully selected adolescents, supported by specialist multidisciplinary teams, may be harmed by delay or refusal. Socialstyrelsen acknowledged these concerns in its own analysis, including continued dysphoria, distress and possible suicide risk, and did not advise abandoning care. Its response was targeted assessment, psychosocial and psychiatric support, systematic follow-up and exceptional access rather than routine hormonal treatment.

Interpretation

Beyond Gender’s reading is that Sweden’s record is significant precisely because its institutions did not claim that young people’s distress was unreal or unworthy of care. Karolinska and Socialstyrelsen accepted the duty to provide respectful, timely and comprehensive support. What they rejected was the assumption that affirmation necessarily means hormones, or that an intervention becomes established paediatric medicine merely because it has been used in specialist services.

The decisive Swedish finding is epistemic: the evidence base did not allow reliable conclusions about central claimed outcomes, while known and plausible harms required consideration. In a gender-critical analysis, that is enough to reverse the presumption. For children, the burden should fall on those proposing interventions that alter normal pubertal development and may set a young person on a pathway towards lifelong medical dependence, compromised fertility or later regret. The appropriate default is careful exploration, treatment of co-occurring difficulties and protection of future options.

It is also important not to overstate the case. Sweden did not impose a nationwide statutory prohibition, and its guidance retained exceptional routes to treatment. The national decision was a restrictive clinical recommendation grounded in uncertainty and risk-benefit assessment. That distinction matters for any accurate European comparison.

Open questions

The central unanswered question remains whether well-designed prospective studies can identify a subgroup of minors for whom benefits clearly outweigh harms over the long term. SBU specifically called for individual-level outcomes, longer observation, data on stopping treatment, bone-health recovery, psychosocial outcomes and changes in gender identity or treatment decisions. Those are not marginal details; they are the outcomes needed for valid consent and safe paediatric practice.

There is also a policy question. Socialstyrelsen urged national documentation and follow-up because earlier systems had not produced the necessary coherent data. Sweden’s 2022 framework made research and registry-quality evidence central to future practice. Whether that evidence can be generated independently, transparently and with meaningful follow-up into adulthood remains a crucial test of the country’s approach.

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