What Happened in Finland and Sweden?

Can they help us solve America's most vicious culture war?

Earlier this year, as the U.S. culture war over trans kids was reaching full tilt, Sweden’s National Board of Health and Welfare (NBHW) released new guidelines for treating young people with gender dysphoria, or what is increasingly called “gender incongruence.” That means puberty suppressants, cross-sex hormones and gender surgeries—often called “gender-affirming care”—to make one’s body appear more like the opposite sex’s—or increasingly, with nonbinary gender medicine, neither sex.

They read: “The NBHW deems that the risks of puberty suppressing treatment with GnRH-analogues and gender-affirming hormonal treatment currently outweigh the possible benefits, and that the treatments should be offered only in exceptional cases.”

Finland’s Council for Choices in Health Care (COHERE) came to almost the exact same conclusion a year earlier, noting, through a translation: “The first-line intervention for gender variance during childhood and adolescent years is psychosocial support and, as necessary, gender-explorative therapy and treatment for comorbid psychiatric disorders.” And: “In light of available evidence, gender reassignment of minors is an experimental practice.” Gender reassignment medical interventions “must be done with a great deal of caution, and no irreversible treatment should be initiated,” COHERE wrote.

These guidelines were in contrast to those proffered by the World Professional Association of Transgender Health (WPATH), an advocacy group made up of activists, academics, lawyers, medical and mental health care providers, which creates “standards of care” that many providers elect to follow. WPATH, which will soon issue its 8th iteration of its SOC, is lowering recommended ages for blockers, hormones and surgeries, and adding chapters on medicine for those with gender identities like non-binary or eunuch. (WPATH did not respond to a request for comment.)

Meanwhile, in the U.S., much of the left, medical associations and activist organizations like the ACLU are claiming doctors agree that gender-affirming medical interventions are “life-saving,” and Assistant Secretary of Health Rachel Levine asserted there’s medical consensus as to its benefits—despite some European countries claiming the opposite. Some activists and gender clinicians in the U.S. still find even WPATH too restrictive.

In Sweden and Finland, the health care community itself was taking on this issue. But here in the U.S. it was playing out in legislatures and courts, the science so politicized that it had become a moral, rather than a medical, issue. This summer alone, Republican Congressmen Jim Banks and Tom Cotton introduced the Protecting Minors from Medical Malpractice Act, which would allow minors who transitioned up to 30 years to sue for malpractice. California introduced SB107, which would allow any child to come to California to medically transition without parental knowledge or consent. Texas had investigated parents of trans kids for child abuse if they transitioned children; earlier, other parents had been investigated, and some had lost custody of their kids, for not transitioning them.

In other words, the U.S. was going completely crazy over the issue of trans kids. Why, I wondered, were Sweden and Finland proceeding so differently, and without the political turmoil that has enveloped what is arguably America’s most virulent culture war? What could they teach us?

**

In mid-July, I spoke with Thomas Linden, director of Knowledge-Based Policy of Health Care at NBHW, over Zoom. He told me that their very first guidelines for treating people under 18 with gender dysphoria (GD) came only in 2015, after increasing awareness among health care professionals of the existence and needs of gender dysphoric youth. (Over 18s have their own guidelines.) “At that time, the focus was very much about the rights issues and making visible the need for care in this group and to secure access to care which was not given evenly across all over the country,” he said. There was still a lot of stigma around what had been previously called “sex changes,” and a lack of knowledge about gender dysphoria.

Those guidelines were broadly welcomed by activist groups, patients, and the medical community, Linden said, because they were the first “to make visible the need for care in a marginalized group.” They allowed for puberty blockers and hormones, but urged clinicians to do long-term follow-up of patients who transitioned and to collect data so policies could be refined based on what they learned.

But what they learned about the science and those partaking of it, and what they didn’t learn, shifted their approach.  

The 2015 guidelines were created with a certain cohort in mind. At the turn of the 21st century, the Dutch had designed a medical protocol for what was then called gender identity disorder, based on a small group, majority male, who had long-lasting childhood-onset gender dysphoria and didn’t have other serious mental health issues. They seemed to fare well after medical transition in adolescence, but the methodology wasn’t terribly reliable.

By contrast, the young people who sought care at Swedish clinics after 2015 were increasingly teen girls with multiple psychiatric diagnoses, and way more of them suddenly appeared than ever before. “It rose from 4 to 77 per 100,000 inhabitants,” Linden said. “The guidelines were written for what we thought was a smaller group of patients and also more homogeneous.”

The same trend was found in Finland, where clinicians first started providing medical treatments for gender dysphoric youth under 18 in 2011. This was due both to increasing awareness of the treatments proffered in the Netherlands and the UK, and what Riittakerttu Kaltiala-Heino, chief psychiatrist in the Department of Adolescent Psychiatry at Tampere University Hospital in Finland, called “political pressure that children and adolescents also have to have access to these assessments”—not just adults. Kaltiala-Heino and her colleagues saw the same drastic increase in female adolescents with GD around 2015. “The number of referrals skyrocketed,” Kaltiala-Heino told me. “They were five-fold more girls coming in.” In addition, they seemed to not have an organic kind of gender dysphoria; rather they “appeared to be very much influenced by other adolescents.”

According to Vogue, 2015 was the “year of trans visibility,” when Caitlin Jenner appeared on the magazine, just a year after Time declared there’d been a “transgender tipping point.” It was also the year the reality show I Am Jazz, about a young, socially, and later medically, transitioned trans girl debuted.

It’s unclear if this infusion of trans storylines into the media contributed to the shift, but whatever the cause, the young people showing up were nothing like the ones in the Dutch research. “We were very astonished to find out that most of the adolescents who were referred to gender identity assessment, they had severe psychiatric problems,” Kaltiala-Heino said. Thus, clinicians couldn’t be sure whether these problems were symptoms of GD or the source of it, since many had long histories of psychiatric problems and GD had only developed as puberty approached.

This is the cohort described in Dr. Lisa Littman’s 2018 research paper, Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria (ROGD)—a paper, and a descriptor, that activists and some health care providers in North America have worked tirelessly to discredit; WPATH took aim at it, too. This cohort was also chronicled in Abigail Shrier’s book Irreversible Damage, so contentious it was briefly banned by Target, despite being accurately reported.

Yet in countries that have actually been keeping track of those seeking care—Canada, the U.K., and Sweden and Finland among them—this emerging demographic has been clearly chronicled.

Graph from Transgender Trend

If in America this ballooning group was seen as evidence of destigmatization of transgender people and medical interventions to service them, as well as a healthcare market growth opportunity, for Swedish and Finish clinicians it was concerning. As Kaltiala-Heino wrote in a 2018 paper, “[V]irtually nothing is known regarding adolescent-onset GD.” In addition, she worried that delaying brain maturation with puberty suppressants would prevent the adolescent task of identity consolidation, and could worsen mental health.

There was also a very high rate of autism among those with adolescent-onset gender dysphoria. “You have a rather severe autism spectrum disorder that has complicated childhood development,” Kaltiala-Heino said. “It was more complicated to find out about young person’s competence to decide about treatment.”

**

Another major shift in knowledge had occurred in both countries. Because regret was so low in the Dutch study, many clinicians assumed that detransition—reverting back to living as one’s natal sex due to regret—was rare. But in Finland, “Young people who regret after top surgery have started to emerge,” Kaltiala-Heino said. “Regrets are not coming immediately. It’s after four, five years, maybe.” One study showed that 76% of detransitioners didn’t inform their clinics of dissatisfaction and regret, so there’s no way to calculate the actual rate of detransition. “We have a great blind spot there in that we don’t know how many [detransitioners] actually they are,” Linden said, adding he thinks it’s more common than previously thought, but probably not pervasive.

A recent small study in the UK showed a 10 percent detransition rate, and a Swedish series, Trans Train (which won the Swedish equivalent of the Pulitzer Prize this year), told the stories of detransitioners and regretters who felt rushed into treatment or realized later they were gay and gender nonconforming, and shouldn’t have changed their bodies. As Sweden’s guidelines noted: “Although the prevalence of detransition is still unknown, the knowledge that it occurs and that gender-confirming treatment thus may lead to a deteriorating of health and quality of life (i.e. harm), is important for the overall judgement and recommendation.”

In the U.S., on the other hand, aside from a segment on 60 Minutes, the mainstream media has largely ignored or silenced detransitioners, with activist groups and even media outlets arguing that it’s too dangerous to hear from them because it might affect access to medical interventions and fuel Republican legislative attempts to delay them until after age 18.

Meanwhile, treatments in Finland had been designed around the idea that some men and boys wanted to be women and girls, and vice versa. But around 2015, Kaltiala-Heino said, the landscape started to change to include new gender identities, like non-binary or genderqueer, and desires for a la carte interventions to match them; the same thing happened in Sweden. There was no research on this cohort or on this kind of care. “We were cautious to conclude that the gender reassignment interventions would be beneficial,” Kaltiala-Heino said. Doctors were worried about intervening “in the completely healthy and functioning body” when research on impacts on bone health or metabolic influence or sexual function haven’t been fully researched. As COHERE’s recommendations noted: “Potential risks of GnRH therapy include disruption in bone mineralization and the as yet unknown effects on the central nervous system.” They added that, in trans girls, “early pubertal suppression inhibits penile growth, requiring the use of alternative sources of tissue grafts for a potential future vaginoplasty.” And: “The effect of pubertal suppression and cross-sex hormones on fertility is not yet known.”

“Individual doctors were under great pressure,” Kaltiala-Heino said. Therefore, “We asked this national body to evaluate this situation and create national guidelines.”

**

COHERE began with a systematic review of literature of the safety and efficacy of treatments, by a neutral expert panel. They found that even studies of adult patients were of such low quality that it was impossible to claim medical and surgical reassignment improved psychiatric problems. And studies of children didn’t clearly assert a correlation between medical interventions and improved mental function. After the evidence review, Kaltiala-Heino’s team finished a paper which found that cross-sex hormones did not improve problems related to “functioning, progression of developmental tasks of adolescence, and psychiatric symptoms.”

“Scientific evidence for any interventions on minors with gender identity indication is actually zero,” Kaltiala-Heino told me. That is, there are some studies that show improvement from interventions, but they are so low quality, so low certainty, that they shouldn’t be extrapolated from. In particular, a Dutch follow-up study often cited as evidence for early hormonal interventions actually compared people who already had good mental health, other than dysphoria, to a group whose mental health was so poor they were deemed ineligible for early intervention. Yet that group was also doing better at follow-up. Other studies were small, or had short follow-ups, and none had been replicated.

Sweden’s findings were similar. Both guidelines suggest therapy as the first-line treatment for GD. “We continue to lack really reliable scientific evidence concerning the efficacy and safety,” Linden said. “We have to have better knowledge. There was really no way to properly assess risk without more and better evidence.” Thus, the focus of guidelines shifted to follow-up, caution and patient safety, with an emphasis on thorough assessment “to minimize the risk of giving the wrong treatment.” These treatments have been declared highly specialized care, requiring permission from the NBHW to conduct, and will be done only in three national university hospitals, which will help with follow-up and data collection. Puberty blockers and cross-sex hormones should be administered within research contexts only.

In both countries, medical interventions for gender dysphoria are not banned, or completely discontinued. “It’s not stopping all treatments. It’s that the [puberty blocking and hormonal] treatment should be offered only in exceptional cases. And this is our language to communicate more risk awareness to the clinicians,” Linden said. But other health care measures such as psychosocial support, he added, “should be available for all who need it.”

In Finland, for patients who fit the profile of participants in the Dutch study, after a prolonged period of evaluation, and with a multidisciplinary team including a psychiatrist, psychologist, social worker and nurse, puberty blockers may be started near the onset of puberty and cross-sex hormones may be possible starting at age 16. Social transition for young people is not advised. But even for those with adolescent-onset gender dysphoria, medical intervention isn’t completely off the table. “It's not that nobody can get it, but it is that there is a very intensive clinical evaluation taking place with the young person and their parents,” Kaltiala-Heino said. Assessments take place at two nationally centralized gender identity clinics, which also initiate any treatments and follow-up the patients over the first years of gender identity-based treatment; gender surgeries are offered only at one center.

Swedish health care providers are still tasked with destigmatizing people with gender dysphoria and the interventions they may want or need. “This is a group of suffering people that need to be given attention. And if you don’t offer them hormonal treatment or surgery, we have to care for them in other ways,” Linden said—mostly through psychological assessment and therapy. Sweden’s guidelines encourage clinicians to “ensure that all young people suffering from gender dysphoria be taken seriously and confirmed in their gender identity.”

**

Why, when we have the same shift in cohort, the same low-quality evidence, is America not following Sweden and Finland’s direction? In the United States, there has been only one nonpartisan evidence review, conducted in Florida earlier this summer. It, too, found “insufficient evidence that sex reassignment through medical intervention is a safe and effective treatment for gender dysphoria.” This significant event got almost no media coverage, even though some of that low-quality evidence had been written up in major publications as “proof” that cross-sex hormones and puberty blockers decrease suicidality.

Perhaps our own blind spot comes from not having a national, nonpartisan group to create guidelines, relying on groups like WPATH to do that work. The closest thing we have is a government organization called the Agency for Healthcare Research and Quality which found that “There is a lack of current evidence-based guidance for care of children and adolescents who identify as transgender regarding the benefits and harms of pubertal suppression, medical affirmation with hormone therapy, and surgical affirmation.” Yet many of our medical advocacy organizations like the American Academy of Pediatrics promote the affirmative model of care; that group has now been accused of suppressing dissent and refusing to conduct a nonpartisan evidence review, despite pediatricians requesting it.

What we have instead are battles playing out in legislatures and courts, which could go on for years. And all the while, we are not conducting long-term research or following up with young patients, or taking seriously the shift in cohort and increase in detransition. What we have here, instead of data collection and evidence review, is culture war.

Linden says the new guidelines did not drop without controversy, or with consensus. “It’s always hard to defend sort of the reasonable middle. The extremes are always more vocal,” he said. Before publishing, NBHW sent draft guidelines to medical groups, patient groups, and trans special interest groups for response. Trans groups, Linden said, “expressed concern for risks associated with more restrictive recommendations, that patients would deteriorate mentally or seek unsecured care abroad and so on, while others found recommendations to be too liberal in view of the different uncertainties,” he said. “There is a there’s a little bit of trench war here also, but I think it’s very far from the situation in United States.”

“Of course there are people who are not satisfied,” said Kaltiala-Heino. But among the clinicians working with gender dysphoric youth, “We find these national guidelines appropriate because the evidence base is so weak.”

In the end, perhaps what makes the Swedish and Finnish approaches so different from the American approach is that they have socialized medicine, not the consumer model here, where gender surgeons have a great financial incentive to ignore risk, and some doctors advertise surgeries directly to children on TikTok. “Our standpoint is that this is a medical treatment, you cannot go into a clinic and order it,” Linden said. “You have to be assessed for your needs and have to be informed of the risks.”

Linden said that though medical treatments are now much rarer, they hope for more research to be done so they can give more precise recommendations as more knowledge is gathered and long-term follow-up completed. “There are a lot of studies,” he said, “but we want to see more of them.”