Finland opts for restraint

In June 2020, the Finnish Council for Choices in Health Care, known as COHERE or Palko, issued a recommendation on the treatment of minors with gender dysphoria. Finland was the first country to move away from the Dutch Protocol as the standard.

The recommendation

According to the council, psychosocial support should be the first step. Any co-occurring mental health problems should be treated first. Hormonal treatment for minors may only be provided following an individual assessment at one of the two specialised university centres, in Helsinki and Tampere. Surgery for minors is not part of the care pathway.

The evidence

The council commissioned an assessment of the available research and described the treatment of minors as an experimental practice. It considered the evidence that the treatment improves psychological wellbeing insufficient.

The reason

Finnish clinicians had found that the young people presenting for treatment differed from the group on which the Dutch Protocol was based: they were more often teenagers whose dysphoria had begun only at puberty, and they frequently had serious mental health problems.

What COHERE is

COHERE is the English abbreviation for the Finnish Council for Choices in Health Care, called Palko in Finnish. The council operates under the Ministry of Social Affairs and Health and determines which treatments are covered by publicly funded healthcare. As a result, a recommendation from the council is more than advice: it establishes which care the public healthcare system provides. The council bases its decisions on an assessment of the scientific evidence, ethical considerations and costs.

The role of Riittakerttu Kaltiala

The Finnish reassessment is closely associated with child and adolescent psychiatrist Riittakerttu Kaltiala. Since 2011, she has led the gender clinic for young people at Tampere University Hospital, one of Finland’s two centres. In 2015, she published a study of the first 47 young people referred to her clinic. The vast majority had been assigned female at birth, and around three-quarters had already received treatment for serious mental health problems before being referred. For many, gender dysphoria had begun only at puberty. This picture differed markedly from the group described in the Dutch research.

What did not change

The recommendation is not a ban. Young people whose dysphoria began in childhood, persists and is not accompanied by serious additional problems may still receive puberty blockers or hormones following an assessment. Adults are covered by separate recommendations. The difference from previous practice is that medical treatment is no longer the default, but the exception.

Later Finnish research

Finland has nationwide registers that make it possible to follow patients over long periods. A 2024 study used these registers to investigate suicide mortality among young people referred to gender clinics between 1996 and 2019. Suicide was rare. The higher risk compared with their peers was found to be associated with these young people’s psychiatric problems, not with gender dysphoria itself. Another Finnish study examined the psychiatric history of people who reversed their transition; see the Finnish study on detransition.

Significance

The Finnish recommendation initially received little attention outside the country, partly because it was written in Finnish. Only when Sweden and England took similar steps did it become clear that this was the beginning of a broader development. Finland is significant because the reassessment came from within the field: from the clinicians themselves, based on what they were seeing in their own consulting rooms.

In the years that followed, Finland’s move was followed by Sweden, the United Kingdom and Norway; see the 2022 Swedish guidelines. More information is available on the page about gender care in Finland and in the archive.