Unfortunately Kaltiala left herself wide open for this criticism. She should not really have done the comparison of treated vs untreated, because the Finnish team were more selective than many other countries in who medically transitioned, and it is quite likely that the most suicidal were not transitioned. This is the likely explanation for the untreated ones showing a trend to a higher rate of suicide. They did try to control for different psychiatric needs within the populations by matching groups based on the number of specialist psych visits. However, this is a blunt instrument, and does not really adequately control for potentially very different reasons for needing psychiatric care. Essentially the problem is that the young people who were attending the gender clinics were not randomised into treatment and non-treatment groups. There was discretion in who was suitable for treatment. I think this is difficult to compensate for afterwards.

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Sullins does suggest this stricter selection for treatment as an explanation. It sounds plausible to me, although I wonder what data (apart from Finland's rate of medical transition) he had from other countries.

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That being said, the paper does have a more robust important conclusion that the 4-fold elevated suicide rate in the trans-identified youth is only the same rate as others with similar psychiatric care needs. Consequently the rate of suicide is likely related to co-existing psychiatric problems.

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Thanks Bernard.

Sullins adds some interesting further observations, which temper his headline finding.

First, he notes that Dhejne et al. (2011), "the only other national registry study of completed suicide", found that suicide mortality among Swedish GR recipients increased dramatically after 10 years, something outside the scope of Ruuska et al., but in keeping with their finding.

Second, He notes that in Finland "only 38% of GD diagnosed persons in treatment proceeded to medical GR. This suggests the presence of assessment, screening and monitoring processes that may inhibit some of the negative consequences of psychiatric morbidity, for example by ensuring better social support or medication compliance, than may be the case in other settings."

Both observations are entirely consistent with a gender-critical perspective.

The pro-transition industry may take Sullins's work as countering Ruuska et al, but that would be a misrepresentation. (Not that that would stop them ...)

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