A study of Finnish youths who sought care from gender clinics has found evidence suggesting that a solid majority go on to receive care for serious psychiatric problems.
Of particular note, the study found that the use of specialist psychiatric care, which the study authors considered a proxy for severe mental health conditions, increased dramatically among adolescents and young adults who underwent gender-transition treatments, including cross-sex hormones or surgeries. The investigators compared the period preceding this group’s first gender-clinic visit with a subsequent period and found the proportion who saw a specialist psychiatrist at least once surged from 10 percent to 61 percent among biological males and from 22 percent to 55 percent among biological females.
The study’s findings, which were based on a large set of comprehensive nationalized health data, have stirred debate and discord about whether they offer evidence that gender-transition treatment, in contrast to what supporters of such interventions routinely assert, does not improve young people’s mental health.
Dr. Jaana Suvisaari, a research professor of mental health disorders at the Finnish Institute of Health and Welfare, explained a key nuance in Finland’s method of allocating mental-health care. “In general,” she said, “specialized services are meant for more severe problems that require psychiatric expertise, and primary care takes care of milder conditions.” This distinction formed the backbone of the study’s findings.
The study authors also compared each individual youth who attended the gender clinics with data regarding four males and four females from the general population, matching them according to birth year and municipality of birth. The proportion to ever receive specialty psychiatric care in the control group stayed essentially constant, at about 15 percent, over time. This suggested that the dramatic shift in the group that received gender-transition treatment was not influenced by overall changes in Finnish youths’ mental health, the study authors asserted.
Dr. Riittakerttu Kaltiala, a professor of adolescent psychiatry at Tampere University, was tasked in 2011 with founding one of Finland’s two youth gender clinics and is the new paper’s senior author. Referring to gender reassignment, as the Finns call gender-transition interventions, she wrote in an email: “Our findings suggest that the hopes—or even promises—of positive effects of medical GR on mental health in young people have been exaggerated.”
The study, which was published April 4 in Acta Paediatrica, defined gender reassignment as receiving cross-sex hormones, gender-transition surgery, or both. It excluded from the analysis psychiatric visits that were directly related to gender-identity assessment or gender-transition treatment.
Dr. Kaltiala and her colleagues analyzed data on nearly 2,100 Finnish youths who first sought care from a gender clinic before age 23 between 1996 and 2019. At that point, their average age was 18 and the bulk of the youth were between 16 and 21.
The study authors measured subsequent psychiatric appointments beginning two years after the first clinic visit, to allow for what amounted to a rough amount of time for the gender-identity assessment process. Dr. Kaltiala said that the assessment process for youth seeking such interventions takes about a year. There was an average of five years of follow-up data per person. Thirty-eight percent of these youth underwent gender-transition interventions.
Forty-eight percent of the youths who first presented to gender clinics in 2010 or later had accessed specialist psychiatric care beforehand. This was exactly twice the proportion to do so among their counterparts from 1996 to 2009. The researchers took this to suggest that the more recent cohort’s baseline mental health was much poorer, which is in keeping with research conducted elsewhere across the Western world that documented a surge in mental health problems among youth presenting to gender clinics, as well as soaring referrals to such clinics.
“The change is hardly attributable to improved recognition of mental disorders, as no similar rise was observed in the control group,” the Finnish investigators wrote.
The researchers argued that their findings gave credence to the theory, anathema among supporters of pediatric gender medicine, that for some adolescents, gender dysphoria may be an outgrowth of deeper psychological problems. And for some youth who seek treatment at gender clinics, the authors wrote, gender dysphoria “may be secondary to other mental health challenges.”
The investigators addressed a common theory that poor mental-health outcomes among youth identifying as transgender are attributable to the stress stemming from stigma toward and mistreatment of transgender people. They noted that with improving attitudes toward transgender people in more recent years, one would have expected, under this theory, to see a decrease in baseline use of specialist psychiatric care among youths presenting at gender clinics. But the opposite occurred. This, along with a surge of youth seeking gender-identity services since the 2010s, they wrote, “may also suggest that for some, mental health challenges may manifest as concerns related to gender identity.”
Most of the Finnish youth who went to the gender clinic but who did not end up receiving gender-transition treatment had previously received specialty psychiatric care, including just over half of the biological males and about two-thirds of the biological females. The study authors theorized that Finland’s policy of restricting gender-transition treatment from people with severe mental illness may help explain why members of this group did not undergo gender reassignment. During the follow-up period, the proportion of this group who received specialty psychiatric care didn’t change substantially.
The investigators controlled the data for differences in the use of specialist psychiatric mental health care prior to the first appointment at the gender clinic, the year of birth, and the date of the first gender-clinic appointment. They then found that, among those who presented at gender clinics, the subsequent proportion who ever used such psychiatric care was comparable regardless of whether the youth ultimately received gender-transition treatment. Compared with the control group, each of the two gender-clinic groups—those who did undergo gender reassignment versus and those who didn’t—used any specialist psychiatric care to a degree that was three to four times greater than in females in the control group and five to six times greater than in the control-group males.
Given the study authors’ comprehensive data set, long follow-up times, and use of age-matched controls, their paper addressed key limitations seen in other studies that have found such interventions are linked to improvements in mental health outcomes. Most studies of youth who undergo gender-transition interventions have relatively small cohorts, short follow-up times of about a year or two, and no control groups; and they suffer from substantial loss to follow-up.
“Arguably, this is better than any other studies,” said Yuan Zhang, an expert in evidence-based medicine who teaches at McMaster University in Ontario. He said the new study, nevertheless, “still has important limitations.” These included the absence of specifics on the timing of gender-transition treatment and on the outcomes of psychiatry visits. He also noted there were considerable apparent baseline differences between those who did versus those who did not receive gender-transition treatment, which complicates comparing the groups.
“People on both sides, they want to focus on whether this treatment is helping or not,” Dr. Zhang said of the fierce debate over pediatric gender medicine in general and this study in particular. “If we think about this as a prognosis study, then I see a lot of strengths with it.” By that, he meant that more broadly, the study more broadly indicates that youth who attend gender clinics tend to have a high subsequent need for specialty psychiatric services, even if they were initially considered mentally healthy and eligible for gender reassignment.
Some critics of the Finnish study, such as Dr. David Healy, a professor of psychiatry at Bangor University in Wales, argued that the surging use of specialty psychiatric care among those who underwent gender reassignment could be explained, at least in part, by the filtering mechanism to which they were subjected. Attending a gender clinic in the first place, such critics have said, means that patients have already progressed through a system that is then more inclined to similarly filter them to a specialist psychiatrist. This bureaucracy, Dr. Healy said, rather than genuine differences in the patients’ mental-health issues, could at least partially explain the dramatic increase in psychiatric referrals.
“The paper will be used in debates, but it’s not telling us a huge amount,” Dr. Healy wrote in an email. “Except,” he said, “that young people who transition don’t live happily ever after.”
Dr. Kaltiala countered that in Finland, a health-equity initiative has meant that young people in the general population are provided routine assessments for the potential need for specialty psychiatric care. These youth are not necessarily monitored to the degree that those attending gender clinics are. But, Dr. Kaltiala argued, “Healthy people usually do not proceed to more specialized assessments from health checks.” Otherwise, she said, the fact that the youth in the general population are routinely assessed suggests that the vast increase in the use of such care among those who underwent gender reassignment is more likely to reflect a true deterioration in their mental health, rather than simply being a natural byproduct of closer monitoring. “Even if the contact was initiated because of what was observed in the gender identity assessment, two years later, any relatively temporary problem would have passed,” Dr. Kaltiala said.
Others have criticized the paper for relying on a binary question—whether the youth received at least one specialty psychiatric appointment—that could mask a wide spectrum of actual need for such care.
“Specialized services,” Dr. Suvisaari said, “are for conditions that require psychiatric expertise. For example, ADHD evaluation is such a service; the conclusion might be that the person does not have ADHD. But naturally, also treatment of more severe mental disorders happens in specialized services.”
The Finnish authors did not break down the number of specialty psychiatry visits during the follow-up period. It did, however, provide such a breakdown for cumulative visits during both comparison periods among all youths who attended gender clinics. These figures suggested that only a small minority of those who had such psychiatric visits attended a small number of them. Twenty-three percent had no such visits, while 11 percent had 1 to 5 visits, 16 percent had 6 to 25, 22 percent had 26 to 100, and 28 percent had over 100. By contrast, three quarters the control group had no such visits and just 4 percent had over 100.
Dr. Kaltiala recalled that during the first few years after founding the Finnish youth gender clinic, she observed that young patients were much worse off psychologically than the existing scientific literature of the time had suggested. She further observed that those who underwent gender reassignment “did not thrive” and that “their adolescent development did not progress and their functioning did not improve.” This was in stark contrast to the promising findings from research out of the Netherlands that gave rise to the global field of pediatric gender medicine.
Over the ensuing years, Dr. Kaltiala began systematically documenting her clinical findings in a series of research papers that, thanks in part to Finland’s meticulous national health records, have produced some of the strongest scientific evidence to date calling into question the general wisdom of providing young gender-distressed people with cross-sex hormones.
All the investigators behind the new paper were also coauthors of a paper published in 2024 that found there was no independent, statistically significant association between taking cross-sex hormones and the rate of suicide deaths among youth attending Finnish gender clinics. It is the only study ever to directly measure suicide deaths when assessing the veracity of widespread claims that these treatments are “life saving.” Other studies addressing this question have all relied on self-reported proxies, such as suicidal thoughts or behaviors.
Systematic literature reviews—the gold standard of scientific evidence—have all found that the research backing the use of gender-transition drugs to treat gender-related distress in youths is weak and unreliable. Advocates of pediatric gender medicine have argued that much of pediatrics relies on weak evidence and that this is not a reason to bar any particular medical practice.
Dr. Zhang was a coauthor of the mammoth report about pediatric gender medicine commissioned by the Trump administration last year that concluded that, given the weakness of the evidence backing benefits and the potential for harm such as infertility, even studying gender-transition treatment in minors in clinical trials did not represent an ethical balance of risks versus benefits.
Mikael Landén is a coauthor of Sweden’s 2023 systematic review on pediatric gender medicine and a principal researcher in medical epidemiology and biostatistics at the Karolinska Institute in Stockholm. He said the new Finnish paper lacks certain granular nuances about the patient population compared with studies that directly follow gender-clinic attendees over time. Nevertheless, he said, it is “a much better study.” The new study’s data, he said, “clearly demonstrate that the use of psychiatric services increases after GR. But the specific reasons and needs for this, as well as the severity of symptoms, are unknown and should be investigated further.”
It was due in part to Dr. Kaltiala’s urging that Finland conducted its own systematic literature review of pediatric gender medicine, which was published in 2019. Given that review’s findings, the nation’s health authorities in 2020 switched to advising great caution when considering gender-transition interventions for minors.
American advocates for pediatric gender medicine have often sought to portray Dr. Kaltiala as being anti–transgender or standing in ardent opposition to minors’ access to these medical interventions.
“Such claims are presented in order to defame me and, through that, belittle the value of my team’s research findings,” Dr. Kaltiala said. “I do not have bias against people undergoing GR and I am not anti-transgender.”
“Some people may indeed benefit from medical GR,” Dr. Kaltiala said. This included, she said, when treatment is “initiated during developmental years.” She added: “Treatment decisions should be based on careful and comprehensive assessment, and our findings pinpoint that medical GR during developmental years is better used with caution.”
