Guest review of Ånger: Ett reportage inifrån transvården

“Whatever you do, don’t take her to see us."

Just after the new year, a new book—Ånger: Ett reportage inifrån transvården—reporting on the state of youth gender medicine in Sweden dropped. I hope there’s an English translation in the works but, in the meantime, Sofie Berg* has done the rest of us a great public service by writing up a fascinating—and often chilling—review of Ånger, alongside her own analysis of the state of gender politics in Sweden today.

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Will new book Ånger shock Sweden more than its authors intended?

Released on January 7 of this year, the book Ånger: Ett reportage inifrån transvården (Regret: A Report From Inside Trans Health Care) provides a fascinating glimpse into what happened when two investigative journalists started taking a closer look at the field of transgender medicine for children and adolescents in Sweden. The journalists in question, Carolina Jemsby and Karin Mattisson, who are also the authors of this book, made a series of documentaries for Swedish public television (SVT) that would go on to not only affect official public policy in Sweden, but put Sweden on the map in the ongoing debate over these issues across the Western world. Ånger retreads much of the ground covered in these documentaries, but does so in greater detail. It also covers much of the controversy surrounding their release, as well as the eventual fallout. 

The first documentary Tranståget och tonårsflickorna (The Trans Train and the Teenage Girls) came out in 2019, and was followed by a “part two” later the same year. Much of the focus was on the huge rise in numbers of young people – teenage girls in particular – who had started showing up at gender clinics across the Western world, and how many of them had come to regret their decision. In the book, Jemsby and Mattisson note that while several of these detransitioners were willing to share their stories, they had a great deal of trouble getting them to do so on camera. In the end, those willing to appear in the first documentary were a detransitioned woman in Finland, and a detransitioned Swedish woman who agreed to do so anonymously. She has since come out publicly.

Late 2021 saw the release of the duo’s third documentary Transbarnen (The Trans Children), and this would prove to be particularly explosive. At this point, the medical scandal became incontrovertible and impossible to contain. At the heart of this documentary is a young child, Leo, whose story is being told by her mother Natalie. Leo is put on puberty blockers at a very young age and kept on them for over four years, with virtually no medical followup. The end result is osteopenia, damage to the spine, and constant pain. During this time, there is also no psychological improvement. The documentary also brings to light additional cases of medical harm that would normally be reported, but which have essentially been covered up.

Leo’s case is greatly expanded upon in the book, and makes for a very shocking read. However, the use of male pronouns for Leo (a female child) in both the documentary, and especially in the book, is jarring. And I say this as someone who is generally unbothered by various pronoun practices, and tends to refer to passing trans people by the pronouns of the sex they appear to be. While there may be very good reasons for the authors’ specific approach to this case, it doesn’t feel at all natural to me to refer to Leo as “he,” for reasons that will become very clear, and start with the introduction to her story on the very first page of chapter one:

Late one evening, Natalie sits at home watching TV when her ten-year-old daughter emerges from her room.

“Could you tell (people) that I’m a boy, instead of a girl?”

Natalie is surprised. This is not something she’s seen coming. Did she have a son, not a daughter? The family had moved to the Stockholm area a few years earlier, from a different part of Sweden. The children have seemed fine, doing sports, singing, and engaging in various activities. But their daughter entered puberty early, she’s the only one in her class to have had her first period, and Natalie knows she hasn’t been doing well.

“I want my name to be Leo, would you call me that? And say that I’m a boy?”

The children’s dad comes downstairs and they sit down together on the couch while their new son, Leo, explains what a trans identity means. He shows his parents different websites with information, tells them he’s done a lot of reading online, and has been making connections with other trans people. Natalie thinks that if this is important to Leo, it definitely needs to become important to them as parents. They promise to read up on everything and get the facts so that they can affirm, support and do the right thing to help him as best they can.

From this point forward, Leo is referred to consistently as a boy, son, and “he,” even though it remains unclear whether Leo still identifies as a boy. It’s a question that is hard to ignore in light of the fact that the book repeatedly comes back to the shifting nature of Leo’s identity. Another quote from a later page:

While his parents talk to the doctor, Leo and a psychologist meet in a different room at the clinic. The psychologist makes a note for the record:

Leo crouches in the chair, looks downward and seems ill at ease. Answers questions briefly, usually with a “don’t know.” Is wearing a sweater with red stripes, a hair ribbon and a necklace. Cradling a red bag and plush toy cat.

Already in the first set of notes, it’s clear that Leo is not a typical case. Leo says that his gender identity varies. Sometimes, he feels more like a boy than a girl, but not always. More than anything, he dislikes having a period and is embarrassed about growing breasts. And he says that there are other problems that have nothing to do with gender dysphoria that he needs help with. When the psychologist asks to hear more, he doesn’t want to go into what it’s about.

It gets worse:

The talks with the psychologist continue at the KID clinic. At his first appointment, Leo is unsure of what he really is; boy or girl. At his next appointment, he comes in with a girl’s name, Nina. With his hair in pigtails, dressed in a skirt and long necklaces, he says that he really is a girl after all. At the appointment after that, he’s non-binary. A bit later, he’s back as Leo, but doesn’t want to define himself as belonging to a particular gender. At no single appointment has the psychologist noted that he feels fully like a boy.

Leo talks about his anxiety, about how he has difficulty eating and sometimes throws up his food, He admits to shoplifting in stores and talks about paranoid delusions. And he never wants to talk about his gender identity, in spite of this being the reason for his appointments. The psychologist tries, but gives up, and finally writes that it is difficult to ascertain whether the issue of gender identity is really central to Leo’s poor mental health.

The fact that any child has been severely harmed by over four years of puberty blockade is bad enough. The fact that this particular child was harmed in this way is almost unfathomable. Perhaps most saddening of all is that it is only when Leo is about to be discharged from the care of the KID clinic at Karolinska Hospital, due to the obvious lack of clarity around her gender issues, that she says she wants to proceed to puberty blockers. Otherwise, she’d lose the connection to the one psychologist she trusts. This is a child clearly asking for any kind of help.

Leo’s story is a very difficult one to read, and never gets better. The blockers don’t help, the gender identity remains unclear, indications that it’s time to move on to cross-sex hormones are met with intense anxiety, and she ends up coming off of the blockers without proceeding down the line so clearly staked out for roughly 98% of these children, though not in time to prevent severe physical harm. In fact, we learn at the very end of the book that the claim often made that bone mineralization will pick back up again when a child is taken off the blockers has not been true for Leo.

The framing of Leo’s story, as that of a child we are invited to think of a very troubled boy – more so than a girl – can probably be chalked up to what I read as an attempt at hedging and throat-clearing, something we see evidence of elsewhere in the book. And I get it. In the telling of this kind of story, you don’t want your work to be framed as transphobic and thus dismissed. Meanwhile, the content itself is explosive enough that no amount of “both-sides-ism” can hope to mask it. The actual ideology behind it all comes through loud and clear. One telling example is that is when Natalie engages in conversation with other affirmative parents:

“Make sure that Leo’s school has been LGBTQ certified,” says one of the parents. “That means the staff has received training in what it means to be trans and in how the school should accommodate trans students. If you encounter transphobia, you need to change schools. No child deserves to have their identity questioned.”

The parents introduce Natalie to RFSL and Transammans. She meets people and organizations who describe themselves as open-minded, tolerant and without prejudice, drivers of a progressive change to society.

“What’s happening now is the revolution of our time. The gender revolution!,” says one parent. “First came the workers’ revolution, then the women’s, and now that of gender; the unnatural division into boys and girls, women and men, that has existed until now will be dissolved. No longer will people be forced into a gender identity.”

Natalie smiles. The notion that her family is part of an ongoing revolution, a necessary transformation of society, appeals to her. Still, she must object, and does so out loud. Gender [sex]** isn’t just constructed from the outside. Almost all people are in fact born as biological men or women, with a penis or a vagina. It’s a difference evident on a chromosomal level. Surely that has to mean something?”

She is met with an ice cold stare.

“That sounded transphobic.”

Jemsby and Mattisson should be lauded for taking organizations like RFSL, and Transammans to task for pushing treatments that are not evidence-based. RFSL is the Swedish equivalent of organizations like Stonewall in the UK, or GLAAD and the HRC in the United States. Transammans – literally “trans-gether,” formed by combining the words “trans” and “tillsammans” (together) – is a trans lobby group. They are both described honestly as activist organizations in the book, and you find clear parallels to what Hannah Barnes uncovered in Time to Think, regarding the connections between the GIDS at Tavistock and the organization Mermaids in the UK. While there is no Susie Green (of Mermaids) figure in this story, some of the clinicians who are quoted in the book make a point of how odd it was to have families come in for appointments flanked by outside representatives. This is not something you see in other areas of medicine. (Another kid comes in with a camera to an appointment, flanked by parents who are very upset when told to put the camera down as that would prevent them from recording the moment for their followers on social media.)

The ideology also peeks through elsewhere, much of it channeled through the concerns of medical professionals. One senior staff member at one of the larger gender clinics allows himself to reflect on the role of social media in young people’s lives. After all, it was around 2010 that smart phones started appearing in the pockets of children everywhere throughout the industrialized world:

But speculating about these things is a sensitive matter. Asking the patients themselves or trying to initiate a public discussion about why so many people are seeking care is something he regards as impossible.

“It would have been akin to suicide for us.” 

Talking about a person’s background or how they felt growing up is fine, but poking the hornet’s nest and asking about social influences was out of the question. Such a conversation might be construed as suggesting that the trans identity isn’t genuine, just a matter of social influence or even worse, a social contagion: “We would be viewed as transphobic.” 

This is why no questions are raised about why certain thoughts have come up, or from where, says the senior clinician. Nothing that can be called into question in any way. He stresses that the motto of gender affirming care is affirmation.

Some clinicians, however, seem to have no qualms about the care they are providing, or the veracity of their claims. The authors visit a support group meeting for parents who seem to be of a more skeptical persuasion: 

One woman shares her story about a parent meeting at Karolinska intended to provide information to parents whose children are undergoing gender identity assessment. They were informed right off the bat that no questions were allowed in the larger group meetings. Instead, the attendees were instructed to write down their questions on notes that would be answered at the end of the meeting. But the woman’s questions were never answered. She later found out that they were deemed to be too critical and might risk alarming the other parents. One question was about what happens to anyone who might regret their transition. Who would be responsible?

The woman got her own meeting with a therapist from the clinic. She was very concerned, and asked how many of those who are assessed end up with a diagnosis.

“Well, all of them get some kind of diagnosis, but this isn’t a psychiatric illness. Our wish is that everyone would be diagnosed with a hormone deficiency,” said the therapist.

Hormone deficiency? He explained that a child born into the wrong sex is deficient in the hormone of the opposite sex. These answers provided no comfort. The woman, who had done her homework on this type of medication, asked what kind of hormone deficiency her daughter had.

“Testosterone, of course. This is something your child was born with, it happens during fetal development.”

The woman asked if there was any scientific proof of this, because if there was it seemed reasonable that there would be documentation. She asked to read the clinic’s information about the topic, but there was nothing to read. She also wondered about the might happen during treatment:

“How do you deal with side effects?”

The answer was quick and unexpected, says the woman:

“There are no side effects.”

Another glimpse into the bizarre otherness of youth gender medicine is shared by a woman working in a prominent position in the legal department at Karolinska. She’s friendly with several of the staff members at the youth gender clinic and finds the field interesting, but hasn’t given much thought to the nuts and bolts of how the care is practiced. However, when her 14-year-old daughter, who had previously been hospitalized for an eating disorder, suddenly announces a trans identity, she takes the opportunity to share her daughter’s story and ask for advice when she runs into one of her acquaintances from the gender clinic. 

In a scene that seems like it’s been cut from one of those nothing-here-is-what-it-seems horror flicks, the clinician takes her by the arm and pulls her to the side where no one can hear them. In a low voice, she says: “Whatever you do, don’t take her to see us. If you do, she is never getting out of here. She’ll be a patient for the rest of her life.” It really makes you wonder how many Jamie Reeds around the world have yet to come forward.

In a scary twist to this woman’s story, one she herself describes as Kafkaesque, she would later have her child removed from her custody. It’s not clear whether she discounted her acquaintance’s hushed warning, or whether her daughter was referred by someone else, but she ends up at the KID clinic where she is given a breast binder and a packer. When this only seems to make their daughter more miserable, the woman and her husband object. The school nurse then contacts child protective services and, supported by KID clinicians, the girl is placed with a foster family. However, she is still dealing with anorexia for which the new family is unprepared and loses a worrying amount of weight. During a home visit, her parents are concerned enough that they decide to keep her at home, whatever the consequences. 

The behavior of the KID clinic seems par for the course in this regard, and the book details other stories of parents who’ve been reported to child protective services. It turns out that the clinic has pre-printed forms specifically for this reason, complete with a generic complaint of what ails the child and why the parent should be viewed as uncooperative. All they need to do is put down the correct names, the date, and the name of the municipality.

The stories of several detransitioners are also told in this book, and they are caught in their own administrative madness. It turns out that changing your legal sex back appears to be more complicated than the first time around. And as is the case around the world, they find themselves utterly misunderstood, and even ignored, by the same institutions who facilitated their transitions. 

Ellen repeatedly expressed doubts and fear of future regret during her years in counseling, all of which are dutifully entered into her records, yet is given hormones the moment she finally gives the go-ahead. She is 24 years old when she detransitions, after four years on testosterone. She tries unsuccessfully to have her case looked at by pretty much every agency available for appeal, as she feels she has received inappropriate treatment. 

Love is another detransitioner who accessed treatment as an adult and lived as a trans man for five years. What is interesting about her story is that she was one of the many angry viewers on the trans activist side who contacted Jemsby and Mattisson after their first documentaries. When she gets back in touch with them, she regrets her transition. It was getting her hysterectomy appointment in the mail that suddenly sparked something in her and caused her to slowly reassess her experiences. 

Both women have had great trouble getting their sex markers changed back, finding themselves in the absurd position of going through the whole process again, and proving that they intend to live as women. Ellen was only accepted back into “womanhood" on her second appeal.

The authors also cover the basics of the Dutch protocol, and its patient zero (whose story appears to be a success case), and how trans care has progressed through the decades. This includes looking at the trans history of Sweden, incidentally the first country in the world to allow the combined change of legal sex with full medical gender reassignment. The law, which was passed in 1972, made the change of legal sex contingent on castration, which eventually made Sweden a target of criticism instead of praise. The requirement for any medical treatment was removed as late as 2013. 

Sweden later became the first country in the world to pay damages to each and every one of the people who had been forced to sterilize themselves in order to access treatment. The fact that this number hovers at around 700 people – in total, over four decades, out of a population of ten million people – tells us something about how rare the phenomenon used to be. More people surely would have chosen to change their legal sex if they didn’t have to go through the full range of physically taxing medical procedures required, but the removal of the castration requirement does little to explain the recent rise in numbers. To their credit, Jemsby and Mattisson set the record straight here. Most of the kids showing up at gender clinics (unfortunately) spend precious little time contemplating sterility. Moreover, the rise in this patient population is seen in many different countries over the same time span, and regardless of differences in legislation. 

There are topics that are less accurately presented. It is alleged, for instance, that: 

People who break gender norms have always existed, and in the early 20th century, words like “transsexual” were coined to describe this. Much later, during the 90s, the word “trans person” came to be used since there was a growing need to advocate for rights pertaining to this marginalized group.

It seems incredibly odd to me to equate gender-nonconforming with transsexual, and I’m not sure anyone in the field (or even most activists now) would make that claim. Most people who might be described as gender non-conforming are not transsexuals (or any kind of trans). There is also the awkward fact (if you know, you know) that not all transsexuals are gender-nonconforming. The effort to push plain old gender-nonconformity under the trans umbrella is a recent one. There is also no explanation given for why simply “trans” became the preferred term in advancing these rights (note that the term “transgender” is rarely used in Swedish). 

The authors do make a note of how our views of what a trans person is has changed over the decades, but they don’t get into the details of what that means. It is presumed to be a good thing, associated with greater tolerance, but having fallen deeper down the rabbit hole than these authors (not necessarily to the benefit of my own sanity), it is hard to not view these glossed-over areas as smoking guns left unexamined at the crime scene. 

However, the book does a pretty good job of plotting a timeline for the events of the past decade. 2015, the “year of trans visibility,” is one the authors come back to a few times. This year provides the setting for one particular talk on the topic of trans youth health care that I assume must have been mentioned by more than one of their sources, as the setting is described in some detail. The speaker at this event was a psychiatrist practicing in one of the country’s few gender clinics (at the time), and the attendees were medical providers, many of whom had already encountered a growing cohort of young patients presenting with gender identity issues. The talk made a strong impression on many of the people in the room, and one ominous assertion proved memorable: “Trans health care is the most life-saving form of health care. The sooner transition is made possible, the better.”

The very same year, The Public Health Agency of Sweden released a 900-page report about trans people’s mental health, and the National Board of Health and Welfare published their first guidelines on the treatment of gender dysphoria in children and adolescents. Over the next few years, more youth gender clinics would open up across the country, using these guidelines for support, even though it was clearly stated in the text that these treatments are based on low, or very low, quality evidence. At the end of the day, the recommendation landed on the side of offering treatment, as “these measures are deemed to be of great benefit to patients, and the risks are comparatively low,” and because “there’s an obvious need for treatment in people with gender dysphoria.” I guess any treatment is better than no treatment even if the only treatment is experimental… When all you have is a hammer—and so on.

In 2020, the National Board of Health and Welfare was commissioned by the government to make an updated version of the guidelines. Things had started happening on the scene. This was after the release of the authors' first two “Trans Train” documentaries and coincided with the Keira Bell case in the UK and the commission of the Cass report, which would go on to present its initial findings the year after. Work on the updated Swedish guidelines made slow progress. Both “camps” were represented in the working group, but the chapters on hormonal treatments for minors were delayed relative to the proposed timeline. 

Then, seemingly out of nowhere in May of 2021, Karolinska made the surprise announcement that they would stop administering hormones and blockers to new underaged patients, generating shock waves around the world. It was this event that put Jemsby and Mattisson in touch with Leo’s mother, Natalie, who was soon revealed to have been the true reason behind Karolinska’s 180-degree turn. 

The telling of these most recent events is provided at the end of the book while also taking us full circle, back to the beginning. We’re treated to how the authors started digging into whether there were more cases like Leo’s, and what is revealed is a cover-up of obvious medical harm. In Sweden, incident reporting in medical care is usually taken very seriously, and medical providers are expected to self-report all instances of obvious injury. As a reader, what I take away from this is that protecting the treatment protocol has been more important than protecting patients from said treatment. The injuries sustained by a not insubstantial number of patients have been treated as inconvenient facts. Not even the upper management at Karolinska learned about this until it was too late.

The timing of events turned out to be crucial. The updated National Board of Health and Welfare guidelines were undergoing final expert review, and were just about to be published. At this point, those advocating for the prescription of puberty blockers to minors appeared to be getting the final say. Among them was Leo’s endocrinologist. At no point during the discussions did s/he mention the adverse effects of puberty blockers seen in his/her own practice, and it was only when one of the other members of the committee mentioned hearing rumors about this that s/he was forced to address the situation. 

Two months after this meeting, the Trans Children documentary was released, and the publication of the updated guidelines was delayed. When the new guidelines finally drop, in February of 2022, the conclusion states that the risks of puberty suppression and gender affirmative hormone treatments for anyone under the age of 18 outweigh the possible benefit. At around the same time, SBU (the Swedish Agency for Health Technology Assessment and Assessment of Social Services) published their now famous evidence review which had also been used for the purposes of informing the new treatment guidelines.

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This could have been the end of the story, but it’s not. As is noted at the very end of the book, several youth gender clinics in Sweden continue prescribing puberty blockers as before. Evidently, some clinicians view all cases as exceptional. It is also unclear at this point what, if anything, is being done by the relevant government authorities to intervene here. 

The fact that these guidelines very nearly went on to make very different recommendations, and that the ideology supporting it has not gone anywhere, should tell us that while one particular battle has been won, the war is not over. It is with a growing sense of embarrassment that I hear critics of gender ideology abroad point to Sweden as an example of sanity and reason over ideology because, on the political side, things are not looking good.

In their book, Carolina Jemsby and Karin Mattisson go to great lengths to stay away from the culture war side of things, going so far as to be at times seemingly unable to connect many of their own dots. And as mentioned previously, I get it. The problem is that whether or not gender identity – as it is currently conceived – is a useful concept at all is central to the discussion around what kind of care is appropriate, for both children and adults. And whether the authors are willing to see it that way or not, I think many of their readers are. It is impossible to read this book and not come away with the realization that many people in this field are ideologically motivated by a worldview we are not even supposed to name, much less call into question.

I’m personally open to the idea that a small number of (adult) people exist for whom some form of medical transition may be of therapeutic value, on balance. However, we need to be honest about what exactly is being treated here. It seems clear to me that the current conception of trans as some kind of misalignment between the body and an essential component of the self (which everyone possesses) is at best pseudo-scientific. It cannot, in the long run, form the basis of safe care. I also don’t think it’s a coincidence that the happiest and most well-adjusted trans people (whom I define as people who have undertaken some form of medical transition) are the ones who understand their biology, their motivations for transitioning, and the limits of what they’ve attempted to achieve. Not involving would-be gender patients in an honest examination of why they feel the way they do, and a discussion of the very real risk of these treatments, entails tremendous harm.

And yet, the ideology of gender identity is looking to score another victory soon – in Sweden. A few years ago, very radical legislation was underway to allow children as young as 12 to change their legal sex, and to allow genital surgeries for minors from the age of 15. This bill was quickly withdrawn following the wake-up call provided by Jemsby’s and Mattisson’s documentaries. 

Having mostly paid attention to events in the English-speaking world, I foolishly assumed that that would be the end of it as far as Sweden was concerned. The world was starting to wake up. Surely, legislators would see the connection between the strange rise in young gender patients and an entirely new and radical view of gender. Sadly, a new take on the old bill has resurfaced and is taking an unorthodox route through the legislative process, to be voted on in April.

The part about genital surgeries for minors has been taken out, and the age at which a person is deemed old enough to request a legal sex change has been raised to 16. It does, however, come awfully close to being just another self-ID law (with very minor extra steps). I cringe knowing how tone-deaf and ill-informed this kind of move is, just as we’re beginning to see serious opposition to the broader ideology all around us. 

Perhaps the timely release of Ånger will once again set Jemsby and Mattisson up to be the ones to help put a stop to the excesses of the ideology, while intending no such thing. Only time will tell.

—Sofie Berg

*Author bio: Sofie Berg has been in the gender identity rabbit hole for about seven years. She has a background in the life sciences and currently works in the governmental sector in Sweden. All translations from the book, Ånger, including any errors, are her own.

**A note on language: Swedish doesn't have the same distinction between "sex" and "gender" as English does. There exists a term, “genus,” which is used for grammatical gender, and in reference to the outward performance of gender (roles), as commonly described by feminist scholars. You rarely hear it outside of academic settings. There is no word that fills the role of “gender” as merely a synonym for sex, because the word for intercourse (“sex”) is not the same as the word for the distinct reproductive roles (“kön”). And so, the modern Swedish term for gender identity is “könsidentitet” (literally sex identity). Furthermore, the words for male and female are generally reserved for animals, and the English dictionary definitions of man and woman as adult human male and female, respectively, become even stricter in Swedish.