Professor Riittakerttu Kaltiala
The National Association of Practising Psychiatrists invited Professor Kaltiala to speak on her experiences in Finland providing medical services for gender questioning youth. What she described was not ideological, but epidemiological. Finland’s centralised health registers, which record diagnoses, treatments, medications and outcomes across the population, allow a degree of longitudinal observation rarely available elsewhere. From this data, Finnish clinicians have been able to observe how the clinical presentation of gender-dysphoric minors has changed over time, and what has happened to them before and after medical intervention.
Professor Kaltiala explained that when Finland established a dedicated gender identity service for minors in 2011, clinicians expected to see a small number of cases, predominantly boys with childhood-onset gender dysphoria and relatively mild psychiatric comorbidity. Instead, referrals rose sharply, and the clinical profile was very different. Approximately 85 percent of presentations were adolescent girls with a mean age just over sixteen. Two-thirds had already required specialist psychiatric treatment for serious mental disorders before presenting with gender concerns. Autism spectrum conditions, depression, anxiety, suicidal ideation, and self-harm were markedly overrepresented, and these conditions typically pre-dated any declared gender dysphoria.
Her published work describing the first two years of Finland’s minor gender service reported an overrepresentation of natal girls with severe problems in adolescent development. Only a small minority had clear childhood-onset gender dysphoria. Many adolescents presenting later showed identity diffusion, regressive development, and complex psychiatric pathology. Once a young person entered a gender pathway, treatment of underlying psychiatric illness was often deprioritised in favour of addressing the gender question, creating what she termed an “exceptionalism” around gender that did not occur in other areas of mental health.
The Finnish data also allowed examination of outcomes after contact with gender services. Register studies showed that these adolescents had received far more specialist psychiatric care both before and after their first gender clinic appointment than matched controls. Over time, the relative risk of needing further psychiatric treatment after presenting to gender services increased. Whether or not young people proceeded to hormonal or surgical intervention made little difference to their subsequent need for psychiatric care. Psychiatric morbidity persisted.
Professor Kaltiala addressed the assertion that medical transition in adolescents prevents suicide. Drawing on national registry data, she reported that gender dysphoria itself did not predict increased suicide mortality in Finnish adolescents. Instead, the strongest predictor of mortality was pre-existing psychiatric morbidity. Medical gender reassignment did not appear to alter this risk.
She also discussed discontinuation. Finnish follow-up studies have found that a measurable proportion of those who begin hormonal transition later stop. More striking than the percentage was the consistent report from those who de-transitioned that their underlying mental health and psychosocial difficulties had received insufficient attention before they embarked on medical transition. In retrospect, many believed these issues had significantly contributed to their wish to transition.
These observations have shaped Finland’s current clinical approach. National guidelines emphasise comprehensive psychiatric assessment, treatment of comorbid mental illness, and exploratory psychotherapy as first-line interventions for gender-dysphoric minors. Medical transition is not ruled out, but it is considered cautiously, on a case-by-case basis, and only after intensive evaluation. Transgender identity itself is not treated as a disorder, but associated psychiatric conditions are actively addressed before irreversible medical steps are contemplated.
In her presentation, Professor Kaltiala referred to broader international developments, including the Cass Review in the United Kingdom and the evolving position of NHS England (NHS England), both of which have called for caution, better evidence, and prioritisation of psychological care. She urged that hormonal interventions in minors be subjected to the same evidentiary standards as any other novel medical treatment and called for a research climate in which scientists can discuss findings without fear of personal attack.
Perhaps the most striking moment came during questions, when she was asked how clinicians could definitively diagnose a case of gender dysphoria that warranted medical reassignment. There was no simple answer. Decisions, she explained, are made by multidisciplinary teams on a case-by-case basis. Identity consolidation, she noted, is the outcome of adolescence, not its starting point. This acknowledgement of developmental uncertainty sits uneasily beside irreversible medical interventions.
For Australian doctors, the central issue is informed consent. When parents and adolescents are asked to consider puberty blockers, cross-sex hormones, or eventual surgery, the quality of that consent depends entirely on the breadth and honesty of the information available to the clinician advising them. If international evidence from jurisdictions with robust data systems is considered too sensitive for routine professional education, doctors are left less able to fulfil their ethical obligation to inform.
The information that Professor Riittakerttu Kaltiala provided in this webinar is directly relevant to everyday medical practice, to conversations with families, and to the solemn duty of obtaining truly informed consent.
Prof Philip Morris AM