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Adam Zivo: So much for 'life saving' gender affirming care

Finish study suggests mental health deteriorates after treatment

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A new Finnish study suggests that “gender affirming care” doesn’t actually improve the mental health of trans-identifying youth, and may, in fact, significantly worsen it. This is certainly vindicating for skeptics who want to restrict access to this treatment, and should prompt a rethink among Canadian policymakers.

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For years, trans activists have claimed that pediatric gender transitions — including puberty blockers and cross-sex hormones — constitute “life saving” health care that stops kids from killing themselves. “Would you rather have a dead son or a live daughter,” they have often said to parents of gender-confused youth, in what essentially amounts to emotional blackmail.

Adam Zivo: So much for 'life saving' gender affirming care Back to video

While these activists have insisted that the science behind pediatric gender care is “settled,” multiple systematic reviews have concluded that there is no reliable evidence of either benefit or harm. In reality, the studies published in this field are overwhelmingly unusable, largely thanks to small sample sizes, short follow-up periods and high rates of patients dropping out of treatment or otherwise becoming unreachable.

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However, this new study, published in Swedish journal Acta Paediatrica, used Finland’s national health databases to provide a uniquely comprehensive long-term assessment of 2,083 youth (aged 23 or younger) who first visited a gender clinic between 1996 and 2019.

The data showed that, when youth underwent medicalized sex reassignment, their need for specialized psychiatric services skyrocketed, suggesting a decline in mental health. Those who visited a gender clinic, but did not begin reassignment, saw a moderate increase in psychiatric visits, suggesting that less invasive forms of gender care were unhelpful.

In other words: not only is the “transition or die” narrative seemingly unfounded, it would appear that gender medicine may actually harm vulnerable youth.

Unsurprisingly, these findings have spurred a maelstrom of debate, with critics arguing, not unreasonably, that the study should be interpreted cautiously, as it has some limitations and flaws. While these details may be technical and occasionally confusing, they cannot be ignored in a good faith policy debate.

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So what does the study actually claim, and how was it structured?

Well, let’s start with some basic demographics: of the patients, only 23 per cent were natal males while 77 per cent were natal females, and only around a third actually initiated medicalized gender reassignment.

As the researchers were unable to directly measure mental health, they focused on visits to specialized psychiatric care as a plausible, albeit imperfect, proxy indicator. According to the study, such care “is only available based on accepted referrals and indicates severe mental disorders,” as regular physicians handle mild or moderate cases in Finland. Appointments related to gender identity assessments, or associated cross-disciplinary teams, were excluded from the study.

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From here, the methodology was straightforward: confirm whether specialized psychiatric services were used before a patient’s first gender clinic visit, and see if this changed afterwards. The first two years after clinical intake were not counted, though, in order “to allow time for the gender identity assessment and potential medical gender reassignment initiation.”

The researchers found that only 15 per cent of the control group used specialized psychiatric services throughout the study period, so this can be considered the normal baseline. But what about dysphoric youth who underwent medicalized gender reassignment?

Before visiting a gender clinic, this group used psychiatric services at roughly the same rate as the control group: 9.8 per cent for natal males and 21.6 per cent for natal females. That may imply that youth who pursued gender reassignment were initially well-adjusted, but it’s also possible that clinicians simply prevented unstable patients from moving forward with hormones or surgery.

In any case, use of psychiatric services exploded after gender reassignment: to 60.7 per cent for males (a six-fold increase) and 54.5 per cent for females (a 2.5-fold increase). This enormous shift suggests (but does not conclusively prove) that medicalized transition worsened mental health.

What about dysphoric youth who visited a gender clinic, but who did not undergo medicalized gender reassignment?

Their use of specialized psychiatric services was already high before visiting a gender clinic, and marginally increased afterwards: females went from 53.1 per cent to 59.7 per cent, while males went from 65 per cent to 67.2 per cent. So it seems that these patients were often already psychologically unwell before visiting a clinic, and that their issues did not alleviate afterwards — so much for “life saving” care.

While these are the main findings of the study, some other trends stand out, too.

The study noted that, between 1996 and 2010, Finnish gender clinics saw an average of 12.4 new patients per year, of which only 23.7 per cent had used specialized psychiatric services before. But between 2011 and 2019, average annual patient intake exploded to 237 — a 20-fold increase — while the pre-clinic specialized psychiatric treatment rate doubled to 47.9 per cent.

This data supports the emerging hypothesis that, while youth who sought gender treatment before the 2010s were mostly (relatively) well-adjusted natal males, they have since been supplanted by increasing numbers of mentally unwell natal female patients. There is mounting evidence that many of these young females are maladaptively latching onto transgender identities as a coping mechanism for unaddressed trauma or neurodivergence.

Many trans activists have, quite predictably, responded to all of these findings by denouncing the study and launching ad hominem attacks against its lead author, Dr. Riittakerttu Kaltiala, whom they have smeared as a bigot.

Kaltiala was tasked with founding one of Finland’s two pediatric gender clinics in 2011, but she later grew disillusioned after observing that, not only were incoming patients often mentally unwell, they did not seem to thrive after undergoing medicalized gender reassignment. She became one of Europe’s leading skeptics of pediatric gender care, and now produces research substantiating her clinical observations.

However, some of the criticisms levied against this study have been sophisticated and fair. Notably, two transgender commentators, Dr. Laura Targownik and Erin Reed, published separate articles pointing out that Kaltiala neglected to specify the quantity, nature and timing of patients’ psychiatric treatments, and that this makes it unclear whether her conclusions are supported.

These objections get a bit technical.

To illustrate: we know that 61.7 per cent of patients accessed specialized psychiatric services after visiting a gender clinic — but how many received, for example, just one treatment across many years? Should they be seen as terribly unwell? If we count them the same as individuals who needed psychiatric treatment on a regular basis, then this arguably exaggerates how troubled Finland’s dysphoric youth were.

Good point, but this bias also applies to the control group. If the study exaggerates how dysfunctional everyone was in roughly equal measure, then that doesn’t explain why psychiatric treatment uniquely exploded among those who underwent medicalized gender reassignment.

Further, the study includes a table that roughly breaks down how many times patients had contact with psychiatric specialists throughout their lifetime. This data suggests that gender dysphoric youth used these services more intensely than their peers (e.g. 27.6 per cent of dysphoric patients had over 100 contacts to specialist psychiatric treatment, while only 4.3 per cent of the control group did).

So if the study were amended to address Targownik and Reed’s objections, there is a good chance that it would still suggest that pediatric gender reassignment worsens mental health.

That being said, Kaltiala’s research would have been stronger if she had provided a breakdown of the number of psychiatric engagements before and after patients first visited a gender clinic. For example: “Between 2-5 years after visiting a gender clinic, dysphoric patients had an annual average of X engagements, while the control group had Y number.” The absence of this kind of granular data analysis is noticeable.

In another critique, Reed wrote that “specialized psychiatric care” is not exclusively reserved for severe disorders, and that it can include relatively mild mental health issues (e.g. ADHD testing). By extension, she argued that increased psychiatric treatment is just a natural and unremarkable side effect of gender affirming care, since patients are closely monitored by clinicians and are ergo more likely to be referred to external supportive services.

Her comparison: you wouldn’t claim that cancer treatment is harmful because it leads to patients having more oncology services afterwards, right?

It’s a decent argument, but a flawed one.

Essentially, Reed’s hypothesis is that dysphoric youth had relatively mild, unaddressed psychiatric issues that were not caused by gender medicine but, thanks to increased monitoring, were caught by gender clinicians. Yet, the truly enormous jump in psychiatric care makes this a bit farfetched. It is also hard to reconcile this theory with the fact that, when gender clinic patients did not medically transition, they did not see a significant jump in psychiatric care, even though they, too, were subjected to increased monitoring.

The third main objection raised by Reed and Targownik is that the Finnish study neither specified what kind of gender reassignment patients received (e.g. hormones, surgery or both), nor how long it took to begin treatment after visiting a clinic.

Reed imagined a scenario where a dysphoric youth waits four years to begin gender reassignment after their initial clinic visit, and then, in the third or fourth year, experiences enough distress from this delay to spur psychiatric treatment. Kaltiala’s study would, by design, record this outcome as a negative consequence of gender reassignment, even though treatment had actually not yet begun.

That’s a great point – but, in a recent New York Sun article, Kaltiala clarified that youth typically underwent a one-year assessment before beginning a medical transition. Ergo, the kind of problematic cases Reed is concerned about probably represent a small minority of the overall patient population, and probably cannot explain the jump in psychiatric treatment following gender reassignment.

While Kaltiala reportedly intends to expand her analysis in the future, her initial paper could have been more comprehensive.

Despite these shortcomings, the study remains far more robust than most literature supporting pediatric gender care. Its findings should be treated cautiously, of course, but it is nonetheless a helpful addition to the debate and shows that the science here is far from “settled.”

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