Dr. Riittakerttu Kaltiala knows gender medicine. She is the top expert on pediatric gender medicine in Finland and the chief psychiatrist at one of its two government-approved pediatric gender clinics, at Tampere University, where she has presided over youth gender transition treatments since 2011. Her research has even been cited—though not accurately—by American supporters of “affirming care” for gender-dysphoric youth. She is one of the last people in the world who could be accused of being “reactionary,” a “transphobe,” or uninformed on the subject of trans health care.
Earlier this month, however, just a few days before Finland passed a law granting its adult citizens the right to have their self-defined gender recognized in government documents, Dr. Kaltiala gave an interview with Helsingin Sanomat, Finland’s liberal newspaper of record. Her comments were a sobering reminder of just how out of step the American medical establishment is with its European counterparts when it comes to treating minors who reject their sex.
The background to this interview is important. Finland was among the first countries to adopt the “Dutch protocol” for pediatric gender medicine, which prescribes—in certain restricted cases—the use of puberty blockers and cross-sex hormones to treat adolescent gender dysphoria. By 2015, however, Finnish gender specialists, including Kaltiala, were noticing that most of their patients did not match the profile of those treated in the Netherlands and did not meet the Dutch protocol’s relatively strict eligibility requirements for drug treatments. Due to the extremely high rate at which children with gender issues come to terms with their bodies (or “desist”) by adulthood, the Dutch protocol requires patients to have gender dysphoria that begins before puberty and intensifies in adolescence. It also requires them to have no serious co-occurring mental health problems, to undergo at least six months of psychotherapy, and to have the support of their family for hormonal treatments.
Within a few years of their country adopting the Dutch protocol in 2011, however, Finnish researchers noticed a sharp rise in the number of patients referred for services. Most of these patients were teenage girls with no history of dysphoria in childhood, and some 68% had a history of severe psychopathology prior to the emergence of their gender-related distress. During this same time period, the U.K.’s largest pediatric gender clinic, at the Tavistock Centre, witnessed a 3,360% surge in patient referrals between 2009 and 2018. Most of the new patients were females—whose representation in the clinic rose 4,400% during this time frame—with a history of serious psychological problems and no gender dysphoria prior to adolescence. Similar trends were being observed in other countries with pediatric gender clinics, including the United States. In 2018, the American physician-researcher Lisa Littman published a study suggesting that teenage girls with high rates of mental health problems were suddenly declaring a transgender identity, often in friend groups and after prolonged exposure to social media.
A year later, Kaltiala and her Finnish colleagues observed in a peer-reviewed article that “[r]esearch on adolescent onset gender dysphoria is scarce, and optimal treatment options have not been established ... The reasons for the sudden increase in treatment-seeking due to adolescent onset gender dysphoria/transgender identification are not known.” This lack of research, and lingering doubts about the Dutch protocol itself (the only attempt to replicate it in the U.K. failed), led health authorities in Finland, Sweden, and the U.K. to conduct systematic reviews of evidence for the benefits and risks of hormonal interventions.
Systematic reviews represent the highest level of evidence analysis in evidence based medicine. The three European countries that did these reviews independently came to the same conclusion: Due to their severe methodological limitations, studies cited in support of hormonal interventions for adolescents are of “very low” certainty. For health authorities in these countries, this meant that the studies were too unreliable to justify the risks and uncertainties of “gender affirming care.” Sweden, Finland, and England have since placed severe restrictions on access to hormones. Although these countries now allow hormones in a very carefully selected cohort of patients who fulfill the criteria of the Dutch protocol, they do so against the findings of their own systematic reviews. That is because the systematic reviews found the Dutch study, on which the Dutch protocol is based, also provides “very low” certainty evidence. Finland’s Council for Choices in Healthcare recognizes medical transition for minors as “an experimental practice.”
Kaltiala was a major force behind the decision to reverse course in Finland. More recently, she testified before the Florida medical boards in support of their decision to restrict access to puberty blockers, cross-sex hormones, and surgeries for minors.
Asked by Helsingin Sanomat what she thought of gender self-identification for minors—a proposed element of the new Finnish law that did not ultimately pass—Kaltiala emphasized that it is “important to accept [children] as they are,” but this means neither pressuring a child to conform to behaviors traditionally associated with the child’s sex nor “negating the body” by confirming that the child’s gender self-identification is real. “In either case,” said the psychiatrist, “the child gets a message that there is something wrong with him or her.” Evidence from a combined 12 studies to date demonstrates that when children with cross-gender or gender variant behavior are left to develop naturally, the vast majority—“four out of five,” according to Kaltiala—come to terms with their bodies and learn to accept their sex. When they are socially transitioned, virtually none do.
That most children desist from cross-sex identification does not necessarily mean that they will no longer experience any distress associated with their bodies; rather, it means that even if such distress lingers, it will not prevent them from becoming reasonably well-adjusted and living a good life. The notion that no human should ever have to experience any discomfort associated with male or female embodiment, including during the turbulent period of puberty, is the utopian promise fueling much of the gender transition industry. There has been a growing movement among gender activists to frame puberty as something that the autonomous, disembodied, self should have a “right” to choose. “Neither puberty suppression nor allowing puberty to occur is a neutral act,” writes the World Professional Association for Transgender Health in the seventh version of its Standards of Care.
Unlike progressive elites in the United States, who seem to regard social affirmation of “transgender children” as little more than an act of kindness, Kaltiala sees it as a powerful intervention in a young person’s psychosocial development with potential for iatrogenic harm (i.e., harm caused by the treatment itself). Gender self-identification in youth is not a mere clerical “formality.” In Kaltiala’s words, “it’s a message saying that this is the right path for you.” Kaltiala thus concurs with NHS England, which recently noted that social transition—using a child’s preferred name and pronouns—is “not a neutral act” but rather one that can solidify what is otherwise likely to be a passing phase into a more permanent state of mind, or “identity,” and put the minor on a path to drugs and surgeries. The NHS now warns of the risks of social transition in children and recommends it only for adolescents who have been diagnosed with gender dysphoria and have provided informed consent.
As for adolescents, Kaltiala distinguishes between the minority whose dysphoria began in childhood and intensified during puberty and those whose dysphoria first appeared after the onset of puberty. For members of the first group, who qualify under the Dutch study, Kaltiala suggested that gender identity discordance may be more stable—although it should be emphasized that there are no controlled, longitudinal studies confirming this observation, and some experts believe that medicalizing teenagers even in this cohort creates a self-fulfilling prophecy. As for teenagers whose dysphoria began in puberty, these are, to repeat, primarily females with extremely high rates of co-occurring mental health conditions. Since “the phenomenon is new” and “there is no scientific knowledge about the constancy of this experience,” Kaltiala explains, it would be irresponsible to cement their gender self-identification in state documents.
Advocates of the American “affirmative” approach tend to ignore the broader trends of mental health collapse among teenagers over the past few decades, a deeply concerning trend that seems to affect girls in particular and is linked to social media use. Utilizing a “minority stress” framework developed in research on homosexuality and borrowed for this purpose, activists insist that co-occurring mental health problems including anxiety, depression, ADHD, and eating disorders are caused by “unaffirmed” gender and can be solved or mitigated through social and medical transition. Autism in particular seems to be especially common in youth who identify as transgender and seek medical transition. A 2019 study on patients at the U.K.’s largest pediatric gender clinic found that 48% were in the autism range. In her book The Gender Creative Child, “gender affirming care” advocate Dr. Diane Ehrensaft suggests that gender transition can even be a “cure” for autism.
“The developmental mission of youth is not helped by the fact that young people’s self-expression is supported and directed from the outside,” Kaltiala said. “The environment should also not commit to identity experiments in a way that might make a later change of direction anxiety-inducing.” These comments are consistent with findings from the Netherlands, where social transition was linked with persistence of gender dysphoria and difficulty coming to term with one’s body and sex.
On the question of why so many minors are rejecting their sex (up to 9.1%, one U.S. study found), Helsingin Sanomat suggested that “many young people grab the idea available in the media and social media that their problems are caused by gender identity and will be solved if others start to see them as members of the other sex.” But that does not work, according to Kaltiala. “A balance of mind does not come from making others do and see what you want.”
The Genevan philosopher Jean-Jacques Rousseau called this amour propre: self-love conditional upon how one is viewed by others. The problem Kaltiala is describing is characteristic of identity politics more broadly: If not just your dignity as a human but your very existence depends upon others agreeing with your self-characterization, you are destined for chronic existential dread. This is not a recipe for authenticity, let alone happiness.
Turning to the question of suicide, which has become virtually the only argument that “gender affirming” activists make in support of their preferred practice, Kaltiala did not pull her punches. The popular “transition or suicide” narrative used by activists to push back against state reform efforts is, in Kaltiala’s words, “purposeful disinformation, and spreading it is irresponsible.”
Much of the public confusion about the suicide issue stems from a simple correlation-causation fallacy. While there is evidence that teenagers who identify as transgender have elevated rates of suicide and suicidality (a behavior that, researchers emphasize, often involved thoughts of suicide or nonfatal self-harming gestures and should not to be confused with actual suicide or serious attempts to end one’s life), there is no evidence that their elevated risk is because of unaffirmed gender identity or that social and medical transition will reduce their risk for self-harm. Studies purporting to find that hormones reduce suicidality are typically designed in such a way that valid inferences about cause and effect cannot be drawn. Considering that roughly three-quarters of teenagers who present to gender clinics these days have preexisting mental health conditions like depression and autism, which are themselves risk factors for suicidality, it is probably more accurate to say that teenagers with suicidal inclinations are more likely to gravitate toward a trans identity.
Thankfully, moreover, suicide is extremely rare even among transgender-identified youth. There was no epidemic of suicides among gender-distressed teenagers before “gender affirming” hormones became available roughly 15 years ago. A study from the U.K. found that the suicide rate among minors seeking medical transition between 2010 and 2020 was 0.03%—nothing close to the 41% risk commonly cited by American activists. Suicide, according to Helsingin Sanomat, was a “very rare occurrence in about ten years among young people seeking gender identity diagnoses. On the other hand, in a large Swedish study, suicide mortality had clearly increased among adults who had received gender reassignment treatments.” For Kaltiala, “it is not justified to tell the parents of young people identifying as transgender that a young person is at risk of suicide without medical treatments and that the danger can be alleviated with gender reassignment.”
Indeed, the suicide discourse that has come to dominate gender transition activism may itself contribute more to youth self-harm than the bans on hormones and surgeries currently being passed in U.S. states. As Alison Clayton has argued in a peer-reviewed paper, “an excessive focus on an exaggerated suicide risk narrative by clinicians and the media may create a damaging nocebo effect (... “self-fulfilling prophecy” ...) whereby suicidality in these vulnerable youths may be further exacerbated.” Tell kids that being suicidal is inherent to being transgender and that only hormones will solve their problem, and many may indeed become suicidal. The “affirm or suicide” discourse also runs counter to the recommendations of the Centers for Disease Control, which emphasizes that “[s]uicide is never the result of a single factor or event” and warns against “presenting simplistic explanations for suicide.” It’s hard to think of a better example of “simplistic explanations” than “trans kids kill themselves when not given hormones.”
Why the obsessive emphasis on the suicide issue? The obvious reason is that if suicide is the expected outcome, any risk from hormones and surgeries is probably worth it. The suicide discourse has the effect, and probably also the intent, of preventing patients and clinicians from doing a careful weighing of pros and cons when deciding on treatment options. It strikes fear into the hearts of parents who worry about the risks and uncertainties about blocking their children’s natural puberty, pumping them full of synthetic hormones, and amputating their healthy breasts as early as age 13. It is also a powerful tool for silencing critics and—crucially—deterring those who have questions about hormonal interventions from raising them in the first place.
Kaltiala thinks that the suicide discourse is being pushed by “adults who have themselves benefited from gender reassignment, have a desire to go out and save children and young children. But they lack understanding that a child is not a small adult.” Activists are driven by a combination of motives including misguided empathy, a savior complex, and projection.
Unlike American doctors who dare question “gender affirmative” orthodoxies, Kaltiala has the backing of professional medical groups in her country. The Finnish Paediatric Society, the counterpart to the American Academy of Pediatrics, has come out against governmental support for gender self-identification in minors in a statement to the Finnish parliament. Likewise, the Finnish Medical Association wrote that “the decision to limit legal gender recognition to adults is a good one.” These statements run directly counter to the American Academy of Pediatrics’ policy since 2018, which, drawing on a highly distorted interpretation of the available research, recommends immediate and uncritical “affirmation” of minors, regardless of age. It also conflicts with the de facto practice in American schools of socially transitioning children upon request, often without knowledge or consent from parents.
When it comes to pediatric gender medicine and related social policy, things are far from perfect in Finland. Compared to the United States, however, it is an oasis of sanity and accountability.
A previous version of this article gave the wrong percentage, 75%, of Finnish pediatric patients presenting for gender identity services who had a history of severe psychopathology prior to the emergence of their gender-related distress. The correct figure is 68%.
Leor Sapir is a fellow at the Manhattan Institute. Follow him on Twitter @LeorSapir.