Transition blues

It looks like medicalised gender change does not affirm good mental health

Photo by Oliver Hae on Unsplash

False advertising

The mental health of young people appears to get worse after they undergo the hormonal and surgical interventions promoted by gender clinics as “lifesaving”, according to an unusually comprehensive study.

“Among adolescents who underwent medical gender reassignment, psychiatric morbidity increased markedly during follow-up—rising from 9.8 per cent to 60.7 per cent in feminising gender reassignment and from 21.6 per cent to 54.5 per cent in masculinising gender reassignment,” the new paper from Finland says.

This long-term retrospective study by Sami-Matti Ruuska and co-authors involves 2,083 gender-distressed patients aged under 23 when referred to specialist clinics; 38.2 per cent went on to have medical interventions.

Thanks to Finland’s comprehensive healthcare register, the study does not suffer from the uncertainty of patients lost to follow-up. And it benefits from comparison with 16,643 matched controls in the general population. (Gender dysphoria as a field has been plagued by poorly designed studies with problems such as small or unrepresentative samples, short-term follow-up, missing patient data, and lack of a control or comparison group.)

Dr Ruuska and his colleagues checked the psychiatric treatment history of the gender dysphoric patients at the time of their first appointment at Finland’s gender clinics and two-plus years afterwards; the median follow-up was almost 5 years and the maximum 25 years.¹

Patients were divided into two cohorts: 1996-2010 and 2011-2019, the latter period coinciding with the unprecedented international spike in gender clinic caseloads.

“Severe psychiatric morbidity is common among gender-referred adolescents and appears to be more prevalent in those referred after the recent surge in referrals,” the paper says. “Psychiatric needs do not subside after medical gender reassignment.”

Fear not

The four Finnish authors, among them the prominent adolescent psychiatrist Professor Riittakerttu Kaltiala, were responsible for a complementary 2024 paper that challenged the “transition or suicide” narrative of gender-affirming clinicians and activists.

Drawing on healthcare register data for this earlier study, the Finnish researchers concluded that suicide was rare among dysphoric youth; medical transition did not appear to reduce suicide risk; and the elevated suicide risk among gender clinic patients was explained by their psychiatric conditions, not by gender dysphoria itself.

Clinical psychologist Ken Zucker, a leading international authority on youth gender dysphoria, welcomed this research as “very important”.

“It is now time to bury the ‘trans kid or dead kid’ trope,” Dr Zucker told GCN.

“Although we know that adolescents and adults with gender dysphoria report suicidal ideation and suicide attempts at a rate higher than non-clinical populations, the rates are, by and large, similar to what one sees in many mental health conditions.”

Chicken and egg conundrum

The Finns’ new paper, just published in Acta Paediatrica, urges clinicians to give priority to these gender patients’ psychiatric conditions, such as depression or anxiety, and the researchers suggest such conditions may not be secondary to gender dysphoria.

“[I]n light of the present findings, severe psychiatric disorders do not appear primarily attributable to [gender dysphoria]. Psychiatric disorders require their due treatment regardless of a young person’s gender identity,” the researchers say.

“It should be noted that in some individuals, medical [gender transition] appears to be linked to deterioration in mental health,” their new paper says, noting the potential for oestrogen to cause depression in males seeking to feminise their bodies.

In the 1996-2010 period, 66 per cent of gender patients had needed specialist psychiatric care two or more years after the first appointment; this compared to 18 per cent of matched controls receiving such specialist care.

In 2011-2019, gender patients were markedly more reliant on psychiatric care than were controls from the general population, both at the first appointment (48 per cent v 15.3 per cent for controls) and at follow-up (61.3 per cent v 14.2 per cent).

The share of gender patients with a history of specialist psychiatric treatment prior to their gender clinic referral doubled in the transition from the 1996-2010 period to 2011-2019.

“No such change was observed among the controls. This suggests that increasingly, adolescents with severe psychiatric morbidity are referred to [gender clinics]. The change is hardly attributable to improved recognition of mental disorders, as no similar rise was observed in the control group.”

The increased psychiatric need of the 2011-2019 cohort is at odds with the minority stress theory, which attributes mental health disorders in trans-identifying patients to a hostile and prejudiced society, the researchers say.

“With the opening up of society with regard to sexual and gender minorities, a decrease in psychiatric morbidity might have been expected in the later [gender dysphoric] cohorts, although reduced stigma may also increase treatment seeking,” they say.

“The notable increase in those contacting [gender clinics] and the increased psychiatric morbidity among them since the 2010s may suggest that, for some, mental health challenges may manifest as concerns related to gender identity.”

UPDATE | The researchers acknowledged the limitation that their study could not analyse in detail why these patients needed psychiatric services.

Asked about this issue, Professor Kaltiala told GCN that healthcare register data used for the study included diagnoses and in-patient periods but not treatment nor information about a patient’s problems related to family life, romantic relationships or work.

One transgender journalist’s critique of the new study suggests that psychiatric appointments are part and parcel of the gender-transition process in Finland and therefore may not point to serious psychiatric morbidity.²

However, Professor Kaltiala said the young people seen by specialised psychiatric services in her country would have “severe disorders”. These services were focused on “those really in need”, consistent with national criteria for health equity.

“In Finland, you do not get admitted to specialist-level services if you don’t have mental disorders at all or [have only] mild disorders and problems,” she said. “Primary-level services are available for needs related to milder disorders and psychosocial difficulties.”

She said the gender-referred youth in the new study were much more likely than matched controls to have a history of severe mental disorders, often dating back some years before they reached the gender clinic.

“Thus, many developed feelings of gender dysphoria in the context of severe disorders,” she said.

“Severe mental disorders during adolescence generally have potential to complicate identity development. It rather seems that feelings of gender dysphoria are sometimes secondary to severe mental disorders.”

If it were the other way around, and the mental disorders were secondary to the dysphoria, those disorders would be “expected to subside with medical gender reassignment”, according to the Dutch treatment protocol adopted internationally, she said.

But this did not happen in the new Finnish study.

Instead, the need for specialist psychiatric services—and therefore the scale of serious mental disorders—increased after medical transition, as the study by Professor Kaltiala and her colleagues reported.

1. The period of two or more years after the first appointment was fixed to allow time for assessment and potential medical intervention.

2. In the study, gender identity assessments and appointments were excluded from the variable of psychiatric treatments.