A Finnish nationwide registry study has found that adolescents and young adults referred to specialised gender identity services were markedly more likely to receive specialist psychiatric care than their peers, both before and after their first clinic visit. The research, published in Acta Paediatrica, also showed that rates of psychiatric treatment did not fall among those who went on to receive hormones or surgery, instead rising sharply after referral. The findings have quickly become a focal point in one of medicine’s most heated debates.
The study drew on comprehensive national health records from Finland, where gender identity assessments leading to medical reassignment are centralised at two university hospitals. It identified 2,083 individuals under 23 who attended these clinics between 1996 and 2019, with an average age of 18.5 at their first visit, and matched each with 8 peers from the general population, creating a control group of 16,643.
Before ever contacting the gender clinics, 45.7 per cent of the gender-referred group had already received specialist psychiatric treatment, compared with 15.0 per cent of controls. Two or more years after the initial visit, 61.7 per cent of the gender-referred youths had specialist psychiatric care, while the control group’s rate remained at 14.6 per cent. The intensity of care was higher among the gender-referred group as well, with 27.6 per cent having more than 100 lifetime psychiatric contacts, versus 4.3 per cent of controls.
When the data were split by time period, a pronounced shift emerged after 2010, coinciding with a surge in referrals. Those referred between 1996 and 2010 showed 23.7 per cent prior psychiatric care, compared with 11.8 per cent of controls. For those referred from 2011 to 2019, prior care rose to 47.9 per cent, versus 15.3 per cent of controls. Yet two or more years after the first visit, the two groups appeared similar: 66.1 per cent of the earlier cohort and 61.3 per cent of the later cohort had received specialist psychiatric care.
The researchers also looked at trajectories by whether patients subsequently underwent medical gender reassignment. Before the clinic visit, individuals who would later receive reassignment had much lower rates of prior psychiatric treatment than those who did not: 9.8 per cent of biological males who later feminised and 21.6 per cent of biological females who later masculinised had prior psychiatric care, compared with 53.1 per cent and 65.0 per cent, respectively, among those who did not proceed with medical transition. The authors note this baseline difference likely reflects clinical screening, since severe, unstable psychiatric illness can delay or withhold treatment in Finland.
Despite starting with lower rates, those who went on to medical gender reassignment experienced sharp increases in specialist psychiatric care two or more years after their initial contact. Among those who underwent feminising reassignment, care rose from 9.8 per cent before the clinic to 60.7 per cent during follow-up, while among those who underwent masculinising reassignment the rate climbed from 21.6 per cent to 54.5 per cent.
Throughout follow-up, rates were broadly similar across the four gender-referred groups, ranging roughly from 55 to 67 per cent. By contrast, psychiatric care among controls remained steady, with only modest increases for those referred but not medically reassigned.
To account for baseline differences, the researchers used statistical models that adjusted for birth year, the year of the initial clinic visit, and prior psychiatric treatment. The models produced hazard ratios indicating that, without adjustments, gender-referred youths who did not receive medical treatment had the highest risk of later specialist care. After accounting for prior treatment, all four gender-referred groups exhibited an elevated risk, roughly 4.7 to 6.1 times that of male controls and 3.0 to 3.7 times that of female controls.
The authors proposed two possible explanations for the rise in psychiatric care among those who undertook medical transition: estrogen therapy may contribute to depressive symptoms in some individuals, and expectations surrounding treatment may not be met. Ruuska said: “There is a dearth of high-quality research in pediatric gender medicine. Previous studies suffer from, for example, small sample sizes, short follow-up times, and lack of control groups. These things leave room for chance variation, i.e., observed findings can be due only to chance, not a real effect or phenomenon.”
He added: “At the same time, medical gender reassignment (hormonal and surgical treatments) for youth suffering from gender dysphoria is oftentimes suggested to be beneficial, even vital, for their mental wellbeing, and has been quickly adopted as the so-called golden standard treatment for gender dysphoria in adolescence.”
“To adopt so widely something with so little high-quality evidence could be considered an outlier in medicine. Medical gender reassignment also carries health risks regarding, for example, fertility, bone density, surgical complications, and even possibly neurocognition. For these reasons it is important to conduct high-quality research on the topic.”
The authors stressed that the study describes group-level patterns rather than individual outcomes. “Severe mental health problems are very common in adolescents suffering from gender dysphoria, and regardless of proceeding to medical gender reassignment, the need for psychiatric treatment due to these disorders does not subside,” Ruuska said. “This does not support the aforementioned suggestion that medical gender reassignment would improve the mental health of these youth. In addition, at least severe mental health disorders do not seem to be explained by gender dysphoria.”
He also argued that the finding of substantial mental health problems before first contact, and their rise over time, suggests that for some adolescents gender dysphoria may reflect other mental health challenges. “In addition, in some, the need for psychiatric treatment emerges only after medical gender reassignment, which may suggest that medical gender reassignment might even have a negative impact on some of these youth’s mental health. The results highlight the need to thoroughly assess these youth’s mental health before and throughout potential medical gender reassignment. Medical gender reassignment is not timely when a youth suffers from concurrent severe mental health problems.”
The study’s conclusions align with earlier registry-based findings and contrast with some studies that focus on self-reported outcomes. Outside researchers acknowledged the strengths of the nationwide dataset while urging caution in interpreting observational records. Marie-Claude Geoffroy, associate professor of psychiatry at McGill University, said the study’s design—with nationwide coverage and minimal loss to follow-up—was strong, but cautioned against causal inferences: “The higher use of specialist psychiatric services among gender-referred youth compared with matched controls is important, but it should not be interpreted causally. Other factors such as residual confounding, selection into treatment, and closer mental health monitoring could also have contributed to the observed differences.”
Geoffroy also noted that residual confounding and selection into treatment—where those receiving hormones or surgery differ in ways that affect later care—could influence the findings. She added that broader research on self-harm and related conditions is essential to understand the full picture and called for prevention and mental health support for all young people.
Annie Pullen Sansfaçon, a professor of social work at the University of Montreal who co-signed one of the critical letters, emphasised that social and environmental factors play a role: “Gender affirming medical care can help improve mental health, but mental health is also influenced by other factors such as levels of parental and peer support or experiences of violence and bullying.”
She urged caution in interpreting the findings, noting that qualitative longitudinal and prospective research involving youth who have accessed gender-affirming care, and those who later detransition, suggests that such care can shape experiences of discrimination, dysphoria, resilience, pride, affirmation and connectedness. “As such, Ruuska et al.’s study needs to be interpreted with caution because it does not account for the person-environment interaction, which may severely limit the findings and what we can conclude from them.”
The authors responded to the criticisms and conducted further analyses, noting that in Finland’s public health system specialist psychiatric care is reserved for severe disorders and ends when a patient is in remission. They re-analysed data five or more years after the first clinic visit and found similar results, and carried out a milestone analysis of care after the final hormone or surgical milestone, which showed a rise in specialist psychiatric care to 48.9 per cent after the last procedure, from 19.2 per cent beforehand, compared with 13.2 per cent after in controls, indicating a markedly elevated risk.
Limitations acknowledged by the researchers include the inability to inspect individual reasons for psychiatric care, and the absence of patient-reported outcomes such as body satisfaction or quality of life. Socioeconomic status, family support and trauma history were also not available in the registries, which could influence mental health trajectories. The authors emphasised that the study cannot establish causation between medical transition and psychiatric care.
Ruuska underscored that the findings describe population-level patterns rather than conclusions about individual care. “There are, but the difficulty in clinical work is to recognise these youth. It is much easier to recognise when these interventions are not timely (i.e., concurrent severe mental health issues). And even in some of these youth, they could be timely later on if the gender dysphoria persists and their mental health ameliorates,” he said. “This is to underline the take-home message of the study: mental health needs of these adolescents need to be recognised and treated.”
The authors indicated they plan further research using the same dataset and that the study—“Psychiatric Morbidity Among Adolescents and Young Adults Who Contacted Specialised Gender Identity Services in Finland in 1996–2019: A Register Study”—was led by Sami-Matti Ruuska, Katinka Tuisku, Timo Holttinen and Riittakerttu Kaltiala.
