Finland Takes Another Look at Youth Gender Medicine

The mismatch between the young people described in the protocol and the patients “on the ground” triggered a policy overhaul.

There was a problem. The children turning up at Finland’s new paediatric gender services didn’t match the profile their doctors were expecting.

The professionals treating gender-distressed children in the country’s brand-new clinics had familiarised themselves with the scientific literature from European countries that had been treating gender-distressed children for years. As a result, psychiatrists like Riittakerttu Kaltiala and her colleagues expected to treat mostly male children whose gender dysphoria had started in childhood and who experienced an uptick in their distress during puberty.

The Dutch protocol, which at the time was relatively new, was the only comprehensive instruction manual they could rely on for guidance. But it was based on a study that had excluded young people with major mental disorders or developmental problems.

The children coming to the gender clinics couldn’t have been more different.

Political decisions meet clinical observations.

Services for gender-distressed minors had been launched in Finland in 2011, and politics mainly drove the decision to create them, Dr Kaltiala told Genspect. Various vocal personalities and organisations advocated for those services in the “best interests” of “transgender kids.”

The task, she said, was handed to the adolescent psychiatry units in two of the country’s university hospitals: Helsinki University Hospital (HUS) and the Tampere University Hospital (TAYS). But Dr Kaltiala and her colleagues began seeing an influx of biological females with considerable psychiatric comorbidities in late adolescence. This ROGD (rapid-onset gender dysphoria) cohort, as they are now called, mostly hadn’t experienced gender problems in their younger years.

The professionals were both worried about what they saw and confused about the contradiction between scientific research and the reality on the ground. In 2015 Kaltiala published a paper drawing attention to the situation. These patients, she said, “do not fit the commonly accepted image of a gender dysphoric minor.”

But like elsewhere, the number of troubled girls referred to the clinics started to rise sharply. The media began reporting stories about gender dysphoria and puberty blockers, and a young trans-identifying teenager, Mesi Kissaniitty, became the face of a burgeoning transgender rights movement. There were a lot of public discussions, said Dr Kaltiala, about whether or not young people with dysphoria weren’t immediately being put on blockers – and if not, why not. The variety of identity presentations increased, as did the variety of body modifications they were asking for, she says. Even the established practices in the adult service couldn’t keep up.

The same pattern repeated across Europe.

In 2019, Dr Kaltiala compared the situation in the other Nordic countries and the UK. She looked at the number of referrals of under-18s every year between 2011 and 2017. A similar pattern emerged. The reasons for the increase are unknown, she said, but could perhaps be the result of “increased awareness of gender identity issues, service availability, destigmatisation as well as social and media influences.”

Regardless, the professionals in Finland’s gender identity services decided they had to do something. “It was us: we asked for national guidelines. There was no research on the phenomenon of adolescent onset gender dysphoria. These patients were simply not those for whom the original Dutch model was intended.”

The national public health body, the Council for Choices in Health Care (COHERE/PALKO), agreed to the need for a solid basis for creating new guidelines and ordered a systematic evidence review from an independent expert panel dedicated to carrying out such assessments. The results were combined with feedback from various interest groups and led to a new cautious set of guidelines issued in 2020 that almost entirely abandoned the controversial WPATH standards of care.

Puberty often resolves dysphoria.

According to the new guidelines (called Medical Treatment Methods for Dysphoria Related to Gender Variance In Minors), cross-sex identification in childhood generally resolves during puberty, even in extreme cases.

As such, even patients who match the typical Dutch protocol profile (male, childhood gender distress, no psychiatric issues) will be offered psychosocial support first and, if needed, psychotherapy. And even though puberty blockers and cross-sex hormones are still available for minors (an argument weaponised by the advocates of gender-affirming care in the US, as Leor Sapir wrote recently), it’s on a carefully-evaluated case-by-case basis in those with early-childhood onset of gender dysphoria and no co-occurring mental health conditions. Surgery is not offered to under-18s.

Sweden and the UK soon took similar steps, but other countries are yet to catch up. The increasing politicisation around the transgender issue will make it harder and harder to do so. How long before other countries look at the Finnish example and recognise that, without the data, it’s all a big experiment?