My country, and others, found there is no solid evidence supporting the medical transitioning of young people. Why aren’t American clinicians paying attention?
Dr. Riittakerttu Kaltiala, 58, is a Finnish-born and trained adolescent psychiatrist, the chief psychiatrist in the department of adolescent psychiatry at Finland’s Tampere University Hospital. She treats patients, teaches medical students, and conducts research in her field—publishing more than 230 scientific articles.
In 2011, Dr. Kaltiala was assigned a new responsibility. She was to oversee the establishment of a gender identity service for minors, making her among the first physicians in the world to head a clinic devoted to the treatment of gender-distressed young people. Since then, she has personally participated in the assessments of more than 500 such adolescents.
Earlier this year, The Free Press ran a whistleblower account by Jamie Reed, a former case manager at The Washington University Transgender Center at St. Louis Children’s Hospital. She recounted her growing alarm at the effects of treatments that sought to transition minors to the opposite sex, and her escalating conviction that patients were being harmed by their treatment.
Although a recent New York Times investigation largely corroborated Reed’s account, many activists and members of the media continue to dismiss Reed’s claims because she is not a physician.
Dr. Kaltiala is. And her concerns are likely to get more attention in the U.S. now that a young woman who medically transitioned as a teenager has just sued the doctors who supervised her treatment, along with the American Academy of Pediatrics. According to the suit, the AAP, in advocating for youth transition, has made “outright fraudulent statements” about evidence for “the radical new treatment model, and the known dangers and potential side effects of the medical interventions it advocates.”
Here, Dr. Kaltiala tells her own story, describing her increasing worries about the treatment she approved for vulnerable patients, and her decision to speak out.
Early in my medical studies, I knew I wanted to be a psychiatrist. I decided to specialize in treating adolescents because I was fascinated by the process of young people actively exploring who they are and seeking their role in the world. My patients’ adult lives are still ahead of them, so it can make a huge difference to someone’s future to help a young person who is on a destructive track to find a more favorable course. And there are great rewards in doing individual therapeutic work.
Over the past dozen or so years there has been a dramatic development in my field. A new protocol was announced that called for the social and medical gender transition of children and teenagers who experienced gender dysphoria—that is, a discordance between one’s biological sex and an internal feeling of being a different gender.
This condition has been described for decades, and the 1950s is seen as the beginning of the modern era of transgender medicine. During the twentieth century, and into the twenty-first, small numbers of mostly adult men with lifelong gender distress have been treated with estrogen and surgery to help them live as women. Then in recent years came new research on whether medical transition—primarily hormonal—could be done successfully on minors.
One motivation of the medical professionals overseeing these treatments was to prevent young people from facing the difficulties adult men had experienced in trying to convincingly appear as women. The most prominent advocates of youth transition were a group of Dutch clinicians. They published a breakthrough paper in 2011 establishing that if young people with gender dysphoria were able to avoid their natural puberty by blocking it with pharmaceuticals, followed by receiving opposite-sex hormones, they could start living their transgender lives earlier and more credibly.
It became known as the “Dutch protocol.” The patient population the Dutch doctors described was a small number of young people—almost all male—who, from their earliest years, insisted they were girls. The carefully selected patients, apart from their gender distress, were mentally healthy and high-functioning. The Dutch clinicians reported that following early intervention, these young people thrived as members of the opposite sex. The protocol was quickly adopted internationally as the gold standard treatment in this new field of pediatric gender medicine.
Concurrently, there arose an activist movement that declared gender transition was not just a medical procedure, but a human right. This movement became increasingly high profile, and the activists’ agenda dominated the media coverage of this field. Advocates for transition also understood the power of the emerging technology of social media. In response to all this, in Finland the Ministry of Social Affairs and Health wanted to create a national pediatric gender program. The task was given to the two hospitals that already housed gender identity services for adults. In 2011, my department was tasked with opening this new service, and I as the chief psychiatrist became the head of it.
Even so, I had some serious questions about all this. We were being told to intervene in healthy, functioning bodies simply on the basis of a young person’s shifting feelings about gender. Adolescence is a complex period in which young people are consolidating their personalities, exploring sexual feelings, and becoming independent of their parents. Identity achievement is the outcome of successful adolescent development, not its starting point.
At our hospital, we had a big round of discussions with bioethicists. I expressed my concern that gender transition would interrupt and disrupt this crucial psychological and physical developmental stage. Finally, we obtained a statement from a national board on health ethics cautiously suggesting we undertake this new intervention.
We are a country of 5.5 million with a nationalized healthcare system, and because we required a second opinion to change identity documents and proceed to gender surgery, I have personally met and evaluated the majority of young patients at both clinics considering transition: to date, more than 500 young people. Approval for transition was not automatic. In early years, our psychiatric department agreed to transition for about half of those referred. In recent years, this has dropped to about twenty percent.
As the service got underway starting in 2011, there were many surprises. Not only did the patients come, they came in droves. Around the Western world the numbers of gender-dysphoric children were skyrocketing.
But the ones who came were nothing like what was described by the Dutch. We expected a small number of boys who had persistently declared they were girls. Instead, 90 percent of our patients were girls, mainly 15 to 17 years old, and instead of being high-functioning, the vast majority presented with severe psychiatric conditions.
Some came from families with multiple psychosocial problems. Most of them had challenging early childhoods marked by developmental difficulties, such as extreme temper tantrums and social isolation. Many had academic troubles. It was common for them to have been bullied—but generally not regarding their gender presentation. In adolescence they were lonely and withdrawn. Some were no longer in school, instead spending all their time alone in their room. They had depression and anxiety, some had eating disorders, many engaged in self-harm, a few had experienced psychotic episodes. Many—many—were on the autism spectrum.
Remarkably, few had expressed any gender dysphoria until their sudden announcement of it in adolescence. Now they were coming to us because their parents, usually just mothers, had been told by someone in an LGBT organization that gender identity was their child’s real problem, or the child had seen something online about the benefits of transition.
Even during the first few years of the clinic, gender medicine was becoming rapidly politicized. Few were raising questions about what the activists—who included medical professionals—were saying. And they were saying remarkable things. They asserted that not only would the feelings of gender distress immediately disappear if young people start to medically transition, but also that all their mental health problems would be alleviated by these interventions. Of course, there is no mechanism by which high doses of hormones resolve autism or any other underlying mental health condition.
Because what the Dutch had described differed so dramatically from what I was seeing in our clinic, I thought maybe there was something unusual about our patient population. So I started talking about our observations with a network of professionals in Europe. I found out that everybody was dealing with a similar caseload of girls with multiple psychiatric problems. Colleagues from different countries were confused by this, too. Many said it was a relief to hear their experience was not unique.
“Medicine, unfortunately, is not immune to dangerous groupthink that results in patient harm,” Dr. Kaltiala writes.
But no one was saying anything publicly. There was a feeling of pressure to provide what was supposed to be a wonderful new treatment. I felt in myself, and saw in others, a crisis of confidence. People stopped trusting their own observations about what was happening. We were having doubts about our education, clinical experience, and ability to read and produce scientific evidence.
Soon after our hospital began offering hormonal interventions for these patients, we began to see that the miracle we had been promised was not happening. What we were seeing was just the opposite.
The young people we were treating were not thriving. Instead, their lives were deteriorating. We thought, what is this? Because there wasn’t a hint in studies that this could happen. Sometimes the young people insisted their lives had improved and they were happier. But as a medical doctor, I could see that they were doing worse. They were withdrawing from all social activities. They were not making friends. They were not going to school. We continued to network with colleagues in different countries who said they were seeing the same things.
I became so concerned that I embarked on a study with my Finnish colleagues to describe our patients. We methodically went through the records of those who had been treated at the clinic its first two years, and we characterized how troubled they were—one of them was mute—and how much they differed from the Dutch patients. For example, more than a quarter of our patients were on the autism spectrum. Our study was published in 2015, and I believe it was the first journal publication from a gender clinician raising serious questions about this new treatment.
I knew others were making the same observations at their clinics, and I hoped my paper would spark discussion about their concerns—that’s how medicine corrects itself. But our field, instead of acknowledging the problems we described, became more committed to expanding these treatments.
In the U.S., your first pediatric gender clinic opened in Boston in 2007. Fifteen years later there were more than 100 such clinics. As the U.S. protocols developed, fewer limitations were put on transition. A Reuters investigation found that some U.S. clinics approved hormone treatments at a minor’s first visit. The U.S. pioneered a new treatment standard, called “gender-affirming care,” which urged clinicians simply to accept a child’s assertion of a trans identity, and to stop being “gatekeepers” who raised concerns about transition.
Around 2015, in addition to the very psychiatrically ill patients, a new set of patients started arriving at our clinic. We began to see groups of teenage girls, also usually from 15 to 17 years of age from the same small towns, or even the same schools, telling the same life stories and the same anecdotes about their childhoods, including their sudden realization that they were transgender—despite no prior history of dysphoria. We realized they were networking and exchanging information about how to talk to us. And so, we got our first experience of social contagion–linked gender dysphoria. This, too, was happening in pediatric gender clinics around the world, and again health providers were failing to speak up.
I understood this silence. Anyone, including physicians, researchers, academics, and writers, who raised concerns about the growing power of gender activists, and about the effects of medically transitioning young people, were subjected to organized campaigns of vilification and threats to their careers.
In 2016, because of several years of growing concern about the harms of transition on vulnerable young patients, Finland’s two pediatric gender services changed their protocols. Now, if young people had other, more urgent problems than gender dysphoria that needed to be addressed, we promptly referred those patients for more appropriate treatment, such as psychiatric counseling, rather than continuing their gender identity assessment.
There was a lot of pressure against this approach from activists, politicians, and the media. The Finnish press published stories of young people dissatisfied with our decision, portraying them as victims of gender clinics that were forcing them to put their lives on hold. A Finnish medical journal ran a piece that took the perspective of dissatisfied activists titled, “Why do trans adolescents not get their blockers?”
But I was trained that medical treatment has to be based on medical evidence, and that medicine has to constantly correct itself. When you are a physician who sees something is not working, it is your duty to organize, research, inform your colleagues, inform a big audience, and stop doing that treatment.
Finland’s national healthcare system gives us the ability to investigate current medical practices and set new guidelines. In 2015 I personally asked a national body, called the Council for Choices in Health Care (COHERE), to create national guidelines for treatment of gender dysphoria in minors. In 2018 I renewed this request with colleagues, and it was accepted. COHERE commissioned a systematic evidence review to assess the reliability of the current medical literature on youth transition.
Around this same time, eight years into the opening of the pediatric gender clinic, some previous patients started coming back to tell us they now regretted their transition. Some—called “detransitioners”—wished to return to their birth sex. These were another kind of patient who wasn’t supposed to exist. The authors of the Dutch protocol asserted that rates of regret were miniscule.
But the foundation on which the Dutch protocol was based is crumbling. Researchers have shown that their data had some serious problems, and that in their follow-up, they failed to include many of the very people who may have regretted transition or changed their minds. One of the patients had died due to complications from genital transition surgery.
There is an oft-repeated statistic in the world of pediatric gender medicine that only one percent or less of young people who transition subsequently detransition. The studies asserting this, too, rest on biased questions, inadequate samples, and short timelines. I believe regret is far more widespread. For example, one new study shows that nearly 30 percent of patients in the sample ceased filling their hormone prescription within four years.
Usually, it takes several years for the full impact of transition to settle in. This is when young people who have entered adulthood confront what it means to possibly be sterile, to have damaged sexual function, to have great difficulty in finding romantic partners.
It is devastating to speak to patients who say they were naive and misguided about what transition would mean for them, and who now feel it was a terrible mistake. Mainly these patients tell me they were so convinced they needed to transition that they concealed information or lied in the assessment process.
I continued to research the issue and in 2018, with colleagues, I published another paper, one that investigated the origin of the surging numbers of gender-dysphoric young people. But we didn’t find answers as to why this was happening, or what to do about it. We noted in our study a point that is generally ignored by gender activists. That is, for the overwhelming majority of gender dysphoric children—around 80 percent—their dysphoria resolves itself if they are left to go through natural puberty. Often these children come to realize they are gay.
In June of 2020 a major event happened in my field. Finland’s national medical body, COHERE, released its findings and recommendations regarding youth gender transition. It concluded that the studies touting the success of the “gender-affirming” model were biased and unreliable—systematically so in some cases.
The authors wrote: “In light of available evidence, gender reassignment of minors is an experimental practice.” The report stated that young patients seeking gender transition should be instructed about “the reality of a lifelong commitment to medical therapy, the permanence of the effects, and the possible physical and mental adverse effects of the treatments.” The report warned that young people, whose brains were still maturing, lacked the ability to properly “assess the consequences” of making decisions they would have to live with for the “rest of their lives.”
COHERE also recognized the dangers of giving hormone treatments to young people with serious mental illness. The authors concluded that for all these reasons, gender transition should be postponed “until adulthood.”
It had taken quite a while, but I felt vindicated.
Fortunately, Finland is not alone. After similar reviews, the UK and Sweden have come to similar conclusions. And many other countries with national healthcare systems are re-evaluating their “gender-affirming” stance.
I felt an increasing obligation to patients, to medicine, and to the truth, to speak outside of Finland against the widespread transitioning of gender-distressed minors. I have been particularly concerned about American medical societies, who as a group continue to assert that children know their “authentic” selves, and a child who declares a transgender identity should be affirmed and started on treatment. (In recent years, the “trans” identity has evolved to include more young people who say they are “nonbinary”—that is, they feel they don’t belong to either sex—and other gender variations.)
Medical organizations are supposed to transcend politics in favor of upholding standards that protect patients. However, in the U.S. these groups—including the American Academy of Pediatrics—have been actively hostile to the message my colleagues and I are urging.
I attempted to address the rising international concerns about pediatric gender transition at this year’s annual conference of the American Academy of Child and Adolescent Psychiatry. But the two proposed panels were rejected by the academy. This is highly disturbing. Science does not progress through silencing. Doctors who refuse to consider evidence presented by critics are putting patient safety at risk.
I am also disturbed by how gender clinicians routinely warn American parents that there is an enormously elevated risk of suicide if they stand in the way of their child’s transition. Any young person’s death is a tragedy, but careful research shows that suicide is very rare. It is dishonest and extremely unethical to pressure parents into approving gender medicalization by exaggerating the risk of suicide.
This year the Endocrine Society of the U.S. reiterated its endorsement of hormonal gender transition for young people. The president of the society wrote in a letter to The Wall Street Journal that such care was “lifesaving” and “reduces the risk of suicide.” I was a co-author of a letter in response, signed by 20 clinicians from nine countries, refuting his assertion. We wrote that, “Every systematic review of evidence to date, including one published in the Journal of the Endocrine Society, has found the evidence for mental health benefits of hormonal interventions for minors to be of low or very low certainty.”
Medicine, unfortunately, is not immune to dangerous groupthink that results in patient harm. What is happening to dysphoric children reminds me of the recovered memory craze of the 1980s and ’90s. During that period, many troubled women came to believe false memories, often suggested to them by their therapists, of nonexistent sexual abuse by their fathers or other family members. This abuse, the therapists said, explained everything that was wrong with the lives of their patients. Families were torn apart, and some people were prosecuted based on made-up assertions. It ended when therapists, journalists, and lawyers investigated and exposed what was happening.
We need to learn from such scandals. Because, like recovered memory, gender transition has gotten out of hand. When medical professionals start saying they have one answer that applies everywhere, or that they have a cure for all of life’s pains, that should be a warning to us all that something has gone very wrong.
