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?

The post Finland Takes Another Look at Youth Gender Medicine appeared first on Genspect.

This summary was written by a Genspect parent.

Many thanks to independent journalist Meghan Daum of the Unspeakable podcast for giving the complex issue of best care for gender-questioning children and youth the attention it deserves by hosting a three-part series this week with Dr. Laura Edwards-Leeper, journalist Lisa Selin Davis, and affected parents. Listen to the second episode (interview with Dr. Laura Edwards-Leeper and two parents) here and the third episode (Lisa Selin Davis) here.

Meghan Daum of the Unspeakable podcast this week has produced a series of podcasts on best care for gender-questioning children and adolescents. In her first podcast, Meghan interviews Dr. Laura Edwards-Leeper. Dr. Edwards-Leeper was trained by one of the creators of the Dutch Protocol, the paradigm for transitioning young people, and adapted it to be used in the US. She is the WPATH Chair of the Child/Adolescent Committee and part of the team writing the new guidelines, SOC 8, to be released soon. Of note, Dr. Edwards-Leeper is the coauthor of an opinion piece with Dr. Erica Anderson passed over by the New York Times for being “outside [their] coverage priorities right now.”

In the podcast, Dr. Edwards-Leeper answers questions related to the dramatic increase in transgender-identified teenagers and mentions issues that could explain this rise in numbers, such as the impact of the internet, peer pressure, and autism. This is why she stresses the importance of comprehensive psychological and developmental assessment for all young people before any attempts at medicalizing them. She is also very concerned by the late teens and emerging adults (18-25) cohort who are being treated under an adult model of care. She is equally alarmed by shifts in the field that are moving people forward quickly without proper assessment or mental healthcare in place.

When asked questions about young people who suddenly present as trans, she admits that this phenomenon is really happening, although there are no clear answers as to why. As a trained clinical psychologist specializing in child and adolescent care, she gets frustrated when people dismiss the phenomenon so quickly as if it’s something that could never happen.

To say that it is impossible for adolescents to experience peer pressure in this area when we know that they experience it in every other area is kind of crazy.

-Dr. Laura Edwards-Leeper

She also acknowledged the social contagion of young people wanting to start hormones because their friends are on them and pointed out that no one is assessing their individual situations to figure out what is really going on and how to best help them.

She noted how trans activists are against any kind of process and don’t speak for the whole community, since regular trans people who don’t agree with these activists feel strongly there must be a process.

Regarding detransitioners, she lamented that the voices of people who have not received adequate care are being silenced to the point that even some providers don’t believe this is occurring. She admitted little is known about detransitioners and that researchers are fearful to investigate them because they are going to be met with criticism and may not like what they’ll find. Her hope is that things will start to shift and everyone will start paying attention to this group, mainly clinics.

She concludes by saying there’s an urgent need to start openly talking about the problems in the field and improve it. She thinks it’s ridiculous and misguided to not talk about these issues and doesn’t see having these conversations as hurting the community. In fact, it is the only way that the field will move forward.

Image from Dr. Laura Edwards-Leeper’s website.

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In a move which will have ramifications around the world, Sweden’s Karolinska Hospital has banned the regular use of puberty blockers and cross-sex hormones for minors. From now on, these drugs will only be prescribed to Swedes under 18 when they are taking part in clinical trials.

This is a major policy U-turn when it comes to gender-questioning minors in Sweden. Much like the case brought (and won) by Keira Bell and Mrs. A against Britain’s GIDS clinic, the message is clear: children can’t consent to consequences they’re too young to understand. As the Karolinska’s Fredrika Gauffin and Svante Norgren put it:

These treatments are potentially fraught with extensive and irreversible adverse consequences such as cardiovascular disease, osteoporosis, infertility, increased cancer risk, and thrombosis. This makes it challenging to assess the risk / benefit for the individual patient, and even more challenging for the minors or their guardians to be in a position of an informed stance regarding these treatments.

The Swedish decision has been in the mail for some time. Referrals to gender clinics in Sweden tumbled by almost a half between 2017 and 2019, with clinicians calling for government to revisit the care protocols — and for the media to be less biased on the topic of transition regret. Like their British counterparts, Swedish doctors are deeply concerned about the possibility of social contagion, which itself is rarely studied.

Scandinavia’s most populous country, then, is waving goodbye to its Germanic cousin, the Netherlands. The Karolinska previously followed the Dutch Protocol, according to which kids as young as twelve can be given access to puberty blockers. But this Protocol seems to be losing ground left, right and centre. To Sweden and the UK can be added Finland, whose new guidelines, issued in 2020, prevent the use of any drug associated with medical transition until “identity and personality development appear to be stable” — in practice, until early adulthood is well underway.

In the Karolinska’s case, it is not just the adverse consequences which Gauffin and Norgren note: it is the “lack of evidence for both the long-term consequences of the treatments, and the reasons for the large influx of patients in recent years.” Ultimately, the Dutch Protocol is an experiment without a formalized control group — a fact never articulated by media outlets describing the model as “life-saving” without examining the evidence for and against this assertion.

Transition regret is a hot topic in Sweden, thanks in part to the three-part documentary Trans Train (Part 1, Part 2, Part 3) investigating the phenomenon. Sweden is frequently lauded for its progressive social values, not least by American liberals, making it harder to dismiss this cultural shift as mere prejudice. Yet certain Americans seem to have a blind spot within their fondness for the Scandinavian social model.

US legislators, take note: while the American culture war rages on, in Europe the tide is turning.

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