Most of the big wins for trans people in Europe were won in court. Legal gender recognition, the end of forced sterilisation in many countries, non-binary recognition: national and European court rulings drove much of that progress.

Healthcare is the exception. That’s the starting point of a new report from TGEU (Trans Europe and Central Asia), published this week: Legal developments on trans-specific healthcare: A review of national case law in the EU. As TGEU puts it on its launch page, “trans-specific healthcare remains largely untested in the courts.”

What the review covers

Pro bono lawyers coordinated by Brussels clearing house Pro Publico combed through case law in nearly all 27 EU member states, mostly from the last 15 years. They found significant cases in only a handful of countries: Austria, Belgium, Croatia, Denmark, France, Germany, Spain and the Netherlands.

Why so few? Healthcare is decided nationally, so the European courts can only do so much. At the European Court of Human Rights, there’s a short list of cases, including Van Kück v. Germany (2003), Schlump v. Switzerland (2009) and W.W. v. Poland (2024). Everything else happens in national courts, where rulings often go unnoticed.

The review includes losses as well as wins, on purpose: it shows what actually sways judges.

Waiting lists: “timely” has limits

Denmark, 2023. A trans man approved for lower surgery was told he could have it at home, in two operations, with a total wait of up to six years. He asked to go to Germany for a single operation instead. The Danish Patient Complaints Agency sided with him. Six years isn’t “timely” treatment, it said, and a region’s limited resources are irrelevant; what counts is the impact on the patient’s life and mental health. It leaned on L. v. Lithuania, where the European Court of Human Rights found a four-year delay violated the right to private life.

Spain (Galicia), 2018. A trans woman had spent more than two years on the waiting list at Málaga, then Spain’s only national reference centre for trans-specific surgery, with years more ahead. Galician law caps surgical waits at 180 days. The court ordered her surgery immediately, at a public centre or a private clinic with full cost coverage, and said anything less would be discriminatory, since anyone waiting for another surgery would already have been treated.

”Cosmetic”? Courts often say no

The Netherlands, 2014. An employer refused to pay a trans employee’s salary while they recovered from surgery, calling it cosmetic. The court disagreed: transition surgery can be medically necessary, so recovery counts as illness and the wages were owed.

Germany, 2022. A trans man whose fertility was affected by transition care was refused reimbursement for fertility treatment by his private insurer. A Wuppertal court ordered the insurer to pay and to cover future treatment, found discrimination and awarded compensation. An appeal is pending.

Spain (Madrid), 2023. A trans man paid for surgery privately after the public system said no reference centre was available, and didn’t refer him elsewhere. The court ordered reimbursement of €20,737.10 and read “vital urgency” broadly enough to include severe psychological distress. His separate claim for an earlier mastectomy failed, because he hadn’t yet completed the year of hormone therapy the protocol required.

Where trans people lost

Germany, 2023. The Federal Social Court rejected a non-binary person’s claim for a mastectomy. It said treatment for gender incongruence now counts as a “new” method that needs a recommendation from Germany’s Joint Federal Committee before insurers must pay. One silver lining: people who had already started treatment are protected and insurers must keep covering them.

Austria, 2012. A trans man had phalloplasty in Munich after Austria refused to authorise surgery abroad. When complications kept him in hospital, he sought full costs of €630 a day. The Supreme Court held that he could only get what equivalent treatment at home would have cost; he got a subsidy of €161.28 a day.

The Balkans case: Croatia

The one case from our region is a work in progress. Croatia’s state health insurance fund began charging trans people for mastectomies it used to cover, despite Ministry of Health guidelines from 2016 that list mastectomy as a necessary procedure for gender affirmation. A trans complainant, with referrals from a psychologist, psychiatrist and endocrinologist, sued under Croatia’s Anti-Discrimination Act.

A county court found in their favour. In 2024, the Supreme Court of Croatia found no discrimination, largely because the hospital had told the fund the procedure was aesthetic, and sent the case back for retrial. It has since been appealed again.

TGEU calls the Supreme Court ruling a setback, but says the county court’s logic, that a public insurer must cover what the Health Ministry itself calls medically necessary, offers “a template for challenging other coverage denials,” backed by Croatia’s comparatively strong anti-discrimination law.

Why it matters

Trans healthcare across Europe is shaped by long waits, unclear rules and quiet administrative refusals that rarely make the news. This review makes those fights visible and gives activists and lawyers ready-made arguments, some borrowed from countries next door.

It’s a technical document, written for trans activists and the lawyers who support them, and it says clearly it isn’t legal advice. But the lesson for everyone is simple: when a system says “wait” or “cosmetic,” courts in several EU countries have said that isn’t the final word.