FIRST, DO NO HARM:

Finland was among the first countries to adopt the "Dutch protocol" for pediatric gender medicine, which prescribes--in certain restricted cases--the use of puberty blockers and cross-sex hormones to treat adolescent gender dysphoria. By 2015, however, Finnish gender specialists, including Kaltiala, were noticing that most of their patients did not match the profile of those treated in the Netherlands and did not meet the Dutch protocol's relatively strict eligibility requirements for drug treatments. Due to the extremely high rate at which children with gender issues come to terms with their bodies (or "desist") by adulthood, the Dutch protocol requires patients to have gender dysphoria that begins before puberty and intensifies in adolescence. It also requires them to have no serious co-occurring mental health problems, to undergo at least six months of psychotherapy, and to have the support of their family for hormonal treatments.

Within a few years of their country adopting the Dutch protocol in 2011, however, Finnish researchers noticed a sharp rise in the number of patients referred for services. Most of these patients were teenage girls with no history of dysphoria in childhood, and some 75% had a history of severe psychopathology prior to the emergence of their gender-related distress. During this same time period, the U.K.'s largest pediatric gender clinic, at the Tavistock Centre, witnessed a 3,360% surge in patient referrals between 2009 and 2018. Most of the new patients were females--whose representation in the clinic rose 4,400% during this time frame--with a history of serious psychological problems and no gender dysphoria prior to adolescence. Similar trends were being observed in other countries with pediatric gender clinics, including the United States. In 2018, the American physician-researcher Lisa Littman published a study suggesting that teenage girls with high rates of mental health problems were suddenly declaring a transgender identity, often in friend groups and after prolonged exposure to social media.

A year later, Kaltiala and her Finnish colleagues observed in a peer-reviewed article that "[r]esearch on adolescent onset gender dysphoria is scarce, and optimal treatment options have not been established ... The reasons for the sudden increase in treatment-seeking due to adolescent onset gender dysphoria/transgender identification are not known." This lack of research, and lingering doubts about the Dutch protocol itself (the only attempt to replicate it in the U.K. failed), led health authorities in Finland, Sweden, and the U.K. to conduct systematic reviews of evidence for the benefits and risks of hormonal interventions.

Systematic reviews represent the highest level of evidence analysis in evidence based medicine. The three European countries that did these reviews independently came to the same conclusion: Due to their severe methodological limitations, studies cited in support of hormonal interventions for adolescents are of "very low" certainty. For health authorities in these countries, this meant that the studies were too unreliable to justify the risks and uncertainties of "gender affirming care." Sweden, Finland, and England have since placed severe restrictions on access to hormones. Although these countries now allow hormones in a very carefully selected cohort of patients who fulfill the criteria of the Dutch protocol, they do so against the findings of their own systematic reviews. That is because the systematic reviews found the Dutch study, on which the Dutch protocol is based, also provides "very low" certainty evidence. Finland's Council on Choices in Healthcare recognizes medical transition for minors as "an experimental practice."

Kaltiala was a major force behind the decision to reverse course in Finland. More recently, she testified before the Florida medical boards in support of their decision to restrict access to puberty blockers, cross-sex hormones, and surgeries for minors.

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