Focusing on legislative debates regarding age of access, we begin with the initial NSP Act, adopted in 2006. However, it is important to note that idea of NSP had long been controversial, and debates had been ongoing for many years leading up to the Act. These related more to clashes in values (e.g. class, nationalism, individualism) and how the problem of drugs was therefore framed (e.g. social justice, disease) than empirical evidence . The stated aim of the proposal for an NSP Act was to improve access to NSP beyond the two existing services that had run since the late 1980s in Lund and Malmö on an experimental basis. It aimed to improve services for ‘heavy drug users’ and to address injecting-related health harms (, pp. 123–128, 131–132). The original proposal was for an age restriction of 20 years, based on two main reasons: need and appropriateness. First, the age of those currently accessing the two existing services was considerably higher, with an average age of 40 among men and 37 among women. The average age had, moreover, been gradually increasing over the years, and the lowest age of anyone accessing the two services was 20. Injecting drug use among under 20s was seen to be very unusual (, p. 135); thus, there was no perceived need. Second, the Government’s view was that society had a duty to not allow teenagers to begin injecting drugs in the first place. The most appropriate intervention was through social services, and compulsory institutional care if needed (ibid p. 136). In other words, NSP was inappropriate. This is in keeping with a scepticism among opponents at the time about the appropriateness of NSP for any age group, when other interventions were available .
While a number of NGOs and the Medicines Authority were of the view that need and not age should determine access  p. 134), the age restriction of 20 was ultimately agreed among the various regional authorities, municipalities and others taking part in the debates, including by the existing two NSPs. However, it was accepted that things may change in future, and the door was left open for amendment if future evaluations deemed it necessary (ibid p. 136).
The NSP Act was, indeed, revised ten years later. In Sweden’s legal framework, regional authorities have responsibility for healthcare, and municipalities have responsibility for social services, education and other issues. Though NSP is therefore run by regional health authorities, the original NSP Act required the support of the municipality in which a service would be opened, granting them an effective veto. For a decade, this prevented the initiation of an NSP in Gothenburg, Sweden’s second largest city, due to a long-standing antagonism to NSP within the municipality. This legal hurdle is important to note because it was a main impetus for the review process, aiming to improve access to NSP nationwide . Among the reforms on the table was the reduction of the age restriction then in place from 20 to 18. Inevitably, the question arose as to whether an age restriction was appropriate at all.
The rationale for reducing the age during the 2016 review was on the evidence that there were those under the age of 20, and indeed under 18, injecting drugs and being at risk of infection with blood borne viruses (the main rationale for the law, and recognised in parliament – see ). Reducing the age of access would also increase opportunities to motivate younger people into treatment . In contrast to the reasoning ten years before (lack of need), the Government now stated that ‘…it is not crucial for the proposal to lower the age limit if the group is large or small, and just as with all types of drug abuse, it can be assumed that there are data gaps’ (, p. 30, 31). More important now, and in keeping with a policy focus on improving health equality, was that ‘[Every individual who can be protected against infectious diseases and who can thus be prevented from spreading these diseases is important. Young people are particularly important in this regard’ (ibid, p. 31; see also ). Indeed, some young people under the age of 20 had already contacted NSP services. All NSP providers that fed into the hearings now saw the age restriction of 20 as a ‘limit’ on their official ‘disease prevention mandate’ (, p. 29).
There was disagreement, however, as to whether to lower the age limit to 18 (, p. 34 & 35). Various universities, NGOs, municipalities and regions agreed with lowering the age. But some important objections and counter-points are worth noting. Gothenburg City Council disagreed on the basis of the State’s obligation to protect children from drugs under the CRC. According to the Council, it was ‘important to clarify that a child perspective should guide needle exchange based on Article 33 of the Convention on the Rights of the Child’, and therefore, ‘the age restriction on needle exchange should not be reduced to 18 years (, p. 32)’.It is unclear why this argument was relevant, however, as the CRC does not apply above the age of 18. Nonetheless, the key point in calling for a ‘child perspective’ recalls concerns about the appropriateness of the service for this age group.
The City Council in Örebro (Sweden’s sixth largest city) also disagreed with lowering the age to 18. In its view, it was more important to provide treatment than to lower the age. Those aged 18–20 should in the first instance instead be offered opportunities to stop injecting (, p. 32). Other municipalities, regions and NGOs felt that the Law on Care for Young Persons was the most appropriate route, including compulsory institutional care. The representative body for Sweden’s regions and municipalities felt that reducing the age on access to NSP would be ‘inconsistent with society’s duties’ under the Law on Care for Young Persons (, p. 34 & 35). Social Services, while not objecting to lowering the age restriction as such, stated in a hearing that young people who inject drugs were ‘already known’ to them (, p. 31).The Government recognised this, agreeing that these young people fell mainly under the mandate of Social Services. Legal minors who inject would be dealt with via the Care of Young Persons (Special Provisions) Act , which results in an assessment for being taken into care by Social Services. But Social Services do not provide NSP, which are under the authority of the regional health bodies. Implied within the argument is that other services, including being taken into care, would obviate the need for NSP access. Here we see the same concerns that had arisen earlier about the appropriateness of NSP versus other interventions, but focused solely on young people. The review, after all, was aiming to increase access to the service, which was clearly by now accepted as appropriate in general.
On the other side of this debate, Lund University argued for no age restriction at all , p. 34), as did Stockholm NSP (, p. 32). This mirrored earlier interventions in 2006 to the effect that need, and not age, should determine access. They were supported by some NGOs, but were outnumbered by the remaining NSP providers and other stakeholders that preferred an age restriction of 18.
The age was ultimately reduced from 20 to 18, with the government recognising that there was injecting drug use among those under 20, and a public health and primary care objective in increasing NSP access. But while the above objections all fed into the hearings, the retention of the age restriction at 18 was not due to concerns about the appropriateness of under 18s receiving sterile needles (implied by the city of Gothenburg), or that other services should be a priority (stated by others). It was to protect the ‘low threshold’ nature of the NSPs themselves. This had not arisen in 2006. Central to this decision was the duty to report under the Social Services Act. NSP staff were ‘assumed to have knowledge of if and when they need to act upon this duty’ which would ‘normally’ be required if encountering under 18s who inject (, p. 32). The view was taken that this would bring an element of coercion into what should be a low threshold service. According to the Government: ‘[A]s it is important that low-threshold activities work on the basis of voluntariness and dialogue rather than coercion and reporting… the Government considers that it would be inappropriate to allow the activities to include persons where notification is a mandatory requirement’ (ibid, p. 32). Stockholm NSP disagreed, stating that the key issue was trust (, p. 32). If the duty to report would breach confidentiality and bring coercion into the programme, then a core tenet of the model would be damaged. However, the solution to the concern about trust is transparency and dialogue. The duty to report situations of children at risk under the Social Services Act, they argued, should not be an impediment to taking in under 18s, so long as there was informed consent (, p. 32).
Thus, what we see in relation to NSP is that a general age-determined standard for access for all took precedence over subjective decisions by staff in dialogue with individual clients. This can be explained in terms of defending the low threshold nature of the services as a value, but it is one that could conflict with the best interests of the individuals subject to the age restriction.