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Denmark has often led the way when it comes to LGBT issues: It was the first country to legally recognize same-sex civil unions in 1989; and back in 1930, Danish artist Lili Elbe became one of the first people in the world to change genders through reassignment surgery.

“You can legally change your gender just by filling in a form—it’s fantastic.”

Now the country has introduced one of the world’s most progressive laws for transgender people. As of September 1, Danish citizens have been able to self-determine their legal gender—without the need for medical approval of any kind.

Niels Jansen, a transgender man from Denmark, welcomes the new law: “You can legally change your gender just by filling in a form saying that you are transgender—it’s fantastic,” he said.

But it wasn’t always this way. Under previous laws that, according to Helle Jacobsen, campaigns coordinator for Amnesty International in Denmark, “date back to a time when castration was also used to ‘cure’ homosexuals and deal with rapists,” people who wanted to change their legal gender had two options: They could either be psychiatrically diagnosed with a mental disorder (known as ‘transsexualism’) and then sterilized through irreversible surgery (removal of the penis and testes for biological males, and uterus and ovaries for biological females)—a procedure that meant anyone wanting to become birth parents could not change their legal gender; or they could live with an identity that didn’t match their legal documents.

“Without the legal change you would have to be ‘outed’ all the time,” said Jacobsen. “So whenever you go to a public office or a bank, your CPR (gendered national identity number) will not be the same as you appear and you have to justify who you are. It made daily life very complicated.”

Before his legal gender change Jansen worried about the confusion his identification could cause. “Personally it was the thought of what could happen that was stressful. I thought, what if I get pulled over by the police in some routine control and they don’t believe that this is my identification?”

He also chose to limit his travel abroad. “I’d heard of others that had problems and I didn’t want to put myself through that,” he said. “So I’m looking forward to traveling with my new passport.”

Waiting for health care to catch up

Jansen changed his legal gender under Denmark’s old law, which required surgery to legally change genders. But he decided to go to Germany and Serbia for the required surgery rather than go through the Danish system.

Denmark’s is now the most legally progressive European country for transgender people.

“I had my uterus and ovaries removed,” he said. “For me personally it wasn’t a problem because I wanted to get it done, but some people don’t want surgical intervention.”

Denmark’s old system was not unique. Twenty European countries and most U.S. states currently require sterilization for a legal gender change and almost all still require at least a medical statement or court order of some kind. But although Denmark may have leaped ahead on the legal side of the issue, Jansen still feels the country lags behind when it comes to health care provision.

“Unfortunately, access to medical care has not followed this great new law,” he said. “In fact, we’re way behind the U.S. and pretty much every other country in the Western world.”

Those wanting to undergo surgery in Denmark must still go through a long and complicated process in order to get the treatment they want, with waiting times of up to a year before the process can even begin.

“The program is very invasive: They evaluate your sex life and write down what you wear every time you show up to note how well you are presenting yourself as whatever gender you want to be,” said Jansen. “And if they evaluate you as not transsexual, they just say, goodbye, we can’t help you.”

He said that although not everyone in the United States has good access to health care, those with money can get treatment.

“That’s not the case here,” he said. “I hope that one day we can get access to medical care in a very similar, simple process through informed consent alone.”

The United States also differs in terms of diagnosis. Rather than labeling transgender individuals with a personality disorder, as Denmark does and which human rights groups claim stigmatizes people and affects their dignity, in the U.S. the term dysphoria is used instead; the feeling of not belonging in your body and the discomfort that comes from that. Rights groups also criticize Denmark for the fact that even under the new law, applicants must be over 18 and married couples must divorce and re-marry as a gay couple if one decides to change gender.

“The World Is Changing”

Despite these issues, Denmark’s new law makes it the most legally progressive European country for transgender people, and globally it is matched only by Argentina. Elsewhere in the world, most countries have no way whatsoever of changing a person’s gender on legal documentation.

There is also a similar movement emerging to include a “third gender” option on legal documentation.

Progress is being made though. In recent years several European countries have dropped the need for sterilization and so too have the states of California, Iowa, New York, and Washington, according to Dr. Rebecca Allison, president of the Gay and Lesbian Medical Association.

There is also a similar movement emerging to include a “third gender” option on legal documentation. Nepal was the first country to do so, in 2007, with Pakistan, Bangladesh, Germany, New Zealand, and most recently Australia, in April, all following suit.

Though the Danish system clearly isn’t perfect, campaigners are hopeful that other countries will follow its example on the issue of legal gender self-determination.

“Trans activist groups worldwide are seeking to change the law in this way,” said Stephen Whittle, vice president of U.K. transgender organization Press for Change.

Whittle believes that such changes come in waves: “The U.K. allowed gender recognition for all legal purposes without any demand for sterilization or any medical input, other than diagnosis of gender dysphoria, in 2005. South Africa followed in 2005, Sweden in 2013 and Holland in 2014. Once the UK had taken this step the others started to fall. The world is changing.”