July 2, 2021

One Year Since Finland Broke with WPATH "Standards of Care"

Finland prioritizes psychotherapy over hormones, and rejects surgeries for gender-dysphoric minors

A year ago, the Finnish Health Authority (PALKO/COHERE) deviated from WPATH's "Standards of Care 7," by issuing new guidelines that state that psychotherapy, rather than puberty blockers and cross-sex hormones, should be the first-line treatment for gender-dysphoric youth. This change occurred following a systematic evidence review, which found the body of evidence for pediatric transition inconclusive. 

Although pediatric medical transition is still allowed in Finland, the guidelines urge caution given the unclear nature of the benefits of these interventions, largely reserving puberty blocker and cross-sex hormones for minors with early-childhood onset of gender dysphoria and no co-occurring mental health conditions. Surgery is not offered to those <18. Eligibility for pediatric gender reassignment is being determined on a "case-by-case basis" in two centralized gender dysphoria research clinics.

The qualifying criteria for gender reassignment of youth, articulated in the 2020 Finnish treatment guidelines, are consistent with the original Dutch protocol, but represent a significant tightening of the more recent practices promoted by WPATH. WPATH Standards of Care 7 (SOC7) allows for hormones and surgery to be offered to youth with a pubertal-onset of gender dysphoria which is frequently complicated by mental health problems or neurocognitive comorbidities (such as ADHD and autism-spectrum disorders), following only a cursory assessment. Assessments by mental health professionals can be bypassed altogether according to the "informed consent model" of care endorsed by WPATH SOC7.

The Finnish guidelines warn of the uncertainty of providing any irreversible "gender-affirming" interventions for those 25 and under, due to the lack of neurological maturity. The guidelines also raise the concern that puberty blockers may negatively impact brain maturity and impair the young person's ability to provide informed consent to the subsequent and more irreversible parts of the Dutch protocol: cross-sex hormones and surgeries.

The Finnish guidelines reflect the growing international concern about the unexplained sharp rise in adolescents presenting with gender dysphoria, which is occurring in increasingly complex developmental and mental health contexts, and often without a childhood history of gender-related distress. There are significant questions as to whether the Dutch protocol (hormonal and surgical interventions for youth), designed for a distinctly different population of high-functioning teens with childhood-onset cross-sex identification and with no significant mental health comorbidites, is appropriate for this novel population.

The guidelines reference a recent Finnish study, which noted that adolescents who were high functioning before cross-sex hormones continued to do well after, but those who had "psychiatric treatment needs or problems in school, peer relationships and managing everyday matters outside of home continued to have problems." The study concluded that "medical gender reassignment is not enough to improve functioning and relieve psychiatric comorbidities."

The guidelines also mentioned that a key study on puberty blockers, which utilized a comparison group of waitlisted adolescents, failed to show a statistically significant difference between the treated and waitlisted groups at the study end-period at 18 months. Although in the abstract of that study, the authors chose to highlight the small improvements in the puberty-blocked group at 12 months, the actual study conclusion – which remains behind a paywall and hidden to most readers – showed that by 18 months, no significant differences could be found.

The Finnish Health Authority states that the guidelines will not be further revised until research is able to: explain the recent sharp rise in adolescents presenting with gender dysphoria; determine whether transgender identities in this population are stable or will evolve; assess whether gender-affirming treatments are able to improve health outcomes of those who present with co-occurring mental health problems, including improvements in depression and suicide; and quantify the rate of regret. 

The Finnish gender identity services program is a worldwide leader in pediatric gender medicine. The 2020 Finnish guidelines represent a strong signal that the pioneers of pediatric medical transition are concerned about unintended harm to the growing number of gender dysphoric adolescents presenting for care. The guidelines echo the concerns voiced by the principal investigator of the Dutch protocol, who warned the medical community in a commentary published in Pediatrics in 2020 that a “new developmental pathway” of gender dysphoria has emerged, including patients with "postpuberty adolescent-onset transgender histories" and “more mental health challenges,” adding, “these youth did not yet participate in the early evaluation studies. This raises the question whether the positive outcomes of early medical interventions also apply to adolescents who more recently present in overwhelming large numbers for transgender care.”

While the official summary of the guidelines has been available on the Finnish Health Authority's site for a year (see June 2020), SEGM has just completed the translation of the full text of the Finnish guidelines for minors. It is an unofficial translation. The original and the translated versions of the guidelines are attached below.


Update July 2023: The guidelines and the appendices (including a systematic review of evidence by Pasternack et al.) are available on the Finnish Health Authority's  (PALKO/COHERE) website at this link