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Gender care in Finland

Finland was in 2020 the first Western country to openly distance itself from the gender-affirmative model for minors — four years before the British Cass Review appeared. The Finnish advisory body COHERE concluded on the basis of a systematic evidence evaluation that psychotherapy and treatment of co-morbid problems must be the first-line treatment, and that hormonal interventions are only justified in exceptional cases. Finland has thereby, together with Sweden, set the tone for the Northern European recalibration of paediatric gender care.

The role of Riittakerttu Kaltiala

A key figure in the Finnish reorientation is Prof. Dr Riittakerttu Kaltiala, head of the child and adolescent psychiatric centre at Tampere University and for years responsible for paediatric gender care in Finland. From 2015 onwards Kaltiala and her team published a series of studies showing that most Finnish young people with gender dysphoria had substantial psychiatric co-morbidity, that medical transition did not alleviate the wider psychological problems, and that the patient group had quickly changed in composition and number. These clinical findings formed the basis for Finnish policy.

The COHERE recommendation (2020, confirmed 2023)

COHERE (Council for Choices in Health Care in Finland, in Finnish PALKO) is the Finnish body that decides which medical treatments are reimbursed from public health care. In June 2020 COHERE published a recommendation on the treatment of gender dysphoria in minors, which was explicitly confirmed in 2023. The full English summary is available via the Finnish government website.

The key points:

• Psychotherapy and psychosocial support are the first-line treatment for minors with gender dysphoria.
• Puberty blockers and cross-sex hormones are only permitted for severe, persistent dysphoria after extensive diagnostics and exclusion of co-morbid causes, and only in carefully weighed individual cases.
• Genital surgery is not recommended for minors.
• Social transition is not a neutral intervention and can influence the natural course — a conclusion later also endorsed by the Cass Review.

Scientific basis

Finland based its policy on a thorough assessment of the international scientific literature, concluding that: (1) a considerable proportion of young people with dysphoria grow out of it during adolescence (desistance, see Steensma et al. 2013), (2) almost all treated young people struggle with co-morbid psychiatric problems, (3) puberty blockers are not the neutral "pause button" they were long held to be, and (4) the long-term effects of hormonal treatment have been insufficiently investigated. These findings run almost entirely parallel to the later conclusions of the Swedish SBU and the Cass Review.

Practical consequences

In Finnish practice young people with dysphoria now first go through an extensive pathway of psychological diagnostics, screening for autism, trauma and other co-morbidity, and psychotherapeutic treatment of underlying problems. Only when it is established that the dysphoria is severe and persistent — and other treatments insufficient — can a medical intervention be considered. In practice that is a small minority. Finland has two specialised centres for paediatric gender care: Helsinki University Hospital and Tampere University Hospital, both bound by the COHERE guidelines.

Legal sex change

Separate from medical care, Finland adopted a new law in 2023 that allows adults to change their legal sex on the basis of self-declaration, without medical requirements. For minors additional requirements apply. The medical and legal pathways have been deliberately decoupled in Finland.