"A special urge to change gender." Gender change treatment in Norway 1952–1982

Summary of a master's thesis submitted at the University of Bergen, the autumn of 2017 by Sigrid Sandal. She was awarded a master's scholarship in 2016 by The Norwegian Queer Archive.

This master's thesis is an investigation of how Norwegian doctors, lawyers and the Norwegian Directorate of Health have thought about and treated genuine transvestism / transsexualism in the period 1952–1982. In order to answer this, the thesis examines what triggered a medical professional discussion and how it developed, and tries to answer what premises were the basis, medically and legally, to be able to carry out gender reassignment surgery during the period. A third key question for the thesis is to examine how a national treatment for transsexualism was established at Rikshospitalet.

As a ground breaking work, this thesis has chosen not to rely clearly on one or more theoretical starting points, but has focused on selected source material. Previously there has been no historical research on transsexualism in Norway. The most important sources are two folders from the Norwegian Directorate of Health, which I had access to at the National Archives. One folder is called Transsexualism, from the Office of Psychiatry. The other folder is also a kind of theme folder, from the Expert Council in cases of sexual assault. Both folders contained assessments, correspondence, professional articles as well as letters and applications from patients and their doctors.

Fluid gender?

To contextualise, the thesis starts with looking at some key features of research on gender and sexuality around the beginning of the 20th century. In many ways it can be said it all starts with new theories about gender. Among other things, ideas about biological sex emerged during the period, as steps along a scale with a fluid transition between what is male and female. This set in motion experiments on gender, first on animals, but also on humans. Towards the middle of the 20th century, knowledge about sex hormones came to play an important role.

When doctor Christian Hamburger in 1952 started the treatment of Christine Jørgensen (1926–1989), he also aimed to see how the female sex hormone had an effect in a male body. Jørgensen was a guinea pig in a study on sex hormones, and his research results were ground breaking.

Christine Jørgensen herself was a pioneer, as well. 2 December 1952 she appeared on front pages of newspapers all over the world, also in Norway. The newspapers told the story of a former soldier who had changed gender to become a woman. The story attracted a great deal of attention and was a direct reason why several transgender people sought help. It also made the sciences take an interest in the phenomenon.

Expert´s choices

In 1953, health director Karl Evang set up an expert committee, consisting of some of the country's leading psychiatrists, to decide whether to treat genuine transvestism, as it was then called, and eventually how. The committee submitted a majority recommendation, signed by Per Anchersen, Gabriel Langfeldt and Nils Kinnerøed. Based on a disagreement around whether to recommend surgical treatment, Johan Bremer dissented. The majority believed there was enough evidence to say the patients would have a better life after surgery and adaptation in a new gender role, and that this could then be recommended after careful assessment and consideration in each case.

Bremer believed there was no basis in the research literature for this claim. He believed one should first and foremost decide whether gender reassignment would be legal, but also whether it would be possible to live as the opposite sex without surgery. He pointed out that doctors in the United States gave written statements to their patients, in case they happened to be stopped by police and asked for ID.

The majority argued on the other hand that the Hippocratic oath required treatment that improved the patient's quality of life, and that gender reassignment was evidently such a treatment. Much of the basis for this claim was how psychiatric or psychotherapeutic treatment alone had not yielded good results in terms of the patient's social adjustment or mental health.

After reading the committee's recommendation and Bremers dissent, health director Evang took Bremers standpoint, and sought further legal considerations. It turned out to be some legal considerations concerning surgical treatment. In 1953, there was a question whether procedures such as castration and amputation of the penis were legal in general. One had to consider using the Sterilization Act of 1934, but also compare penis amputation to verdicts on serious injury, done on basis of the Penal Code.

An assessment by the Ministry of Justice, saw the operative treatment of gender reassignment as legal, if one could come up with a medical justification.

A practice is created

In the early 1960s, the Norwegian Directorate of Health, with the support of the Ministry of Justice, gave green light to gender reassignment treatments if a doctor could give a recommendation after a professional assessment. The doctors called for guidelines and regular routines.

After the operations were completed, new challenges emerged, such as changing names, gender status or legal gender and rules for entering into marriage. Following assessments from the Ministry of Justice, it was concluded that patients could be given a gender-neutral name during the process of carrying out gender reassignment.

After the change was completed, and after it could be confirmed that the person was no longer fertile, one could get a new gender status and choose a more gender-specific name. One had to be sterile because a pregnant man giving birth was a disturbing thought. A similar practice was adopted by law in Sweden in 1972.

In the 1970s, there were no formal guidelines in place regarding gender reassignment. Referrals, implementation of operations and legal changes were made as informal collaborations between therapists such as Anchersen and psychiatrist Jørgen Hermann Vogt, with surgeons at Rikshospitalet. Change of name and gender status were arranged, case by case through application to the Ministry of Church and Education. The new health director Torbjørn Mork was satisfied with these ad-hoc solutions. But more and more people were not.

New health services

In 1977, a counselling service for homosexuals was established at the Oslo Health Council. This was a health service, the first of its kind, aimed at homosexuals. There they met patients with problems related to gender identity, some also talked about changing gender. The counselling services wanted to help, but had little expertise in transsexualism, gender reassignment and gender identity issues. They also found it difficult to know where to refer these patients. There were no formal service, guidelines or recommendations. The counselling service thus contacted the Norwegian Directorate of Health, Anchersen, surgeons at Rikshospitalet and others who worked with transsexuals, to come up with possible solutions. The aim of the Counselling Service was to send relevant patients to persons with competence to deal with any transsexualism, and to prepare a treatment plan that would be carried out by a formalized interdisciplinary team, preferably based in Oslo.

The initiative met with initial opposition from Anchersen and the director of health, who believed that the current practice worked satisfactorily. But the former changed his position after learning about patients receiving treatment from other doctors on what he believed to be wrong basis. Anchersen then saw the benefit of sending all relevant patients to a formalized group for evaluation and possible treatment. The Norwegian Directorate of Health, for its part, still had reservations. Much of the argument for maintaining the established practice, was to avoid use of time and resources. At the end of the 1970s, about one patient was operated a year. Since 1963, around 12 operations had probably been carried out by this time. Transsexualism was seen as a particularly complex and rare condition, for which the directorate found it difficult to provide large resources to formalize a practice. Especially since they thought it worked well as it was. The director of health also feared that a formalization would draw attention to the procedure and the diagnosis, and that this would generate a large influx of new patients, like after the publicity surrounding Christine Jørgensen.

Right to gender

It has not been possible to set a date for when the Norwegian Directorate of Health finally gave the go-ahead or approved a formalized professional team.  There is no confirmation to be found in the source material on which this assignment is based. It is known today as the National treatment Centre for transsexualism, and is part of the psychosomatic department at Rikshospitalet in Oslo.

The informal practice of sterilization as a condition for changing legal gender ended when a new law on changing gender was adopted on 1 July 2016. With the new law, operative sterilization is no longer a condition. Changing gender is now open to everyone, regardless of a psychiatric diagnosis.

The treatment has not changed after the new law. Gender-confirming treatment is provided for persons diagnosed with transsexualism.

My findings show how the Norwegian Directorate of Health has been cautious in the development of treatments and rights for transsexuals and transgender people in Norway. The project has also demonstrated how the progress in treatments and rights, largely has been driven by patients and some particularly committed medical specialists. There is much in the treatment of early times that for many reasons would not be acceptable today, and it is often easy to paint the past black in that way.

I hope this thesis can be helpful in understanding how the Norwegian health authorities have been thinking and why.