It’s one of the commonplaces that young people who have gender dysphoria (“GD”) will experience both reduced psychiatric problems and reduced suicides if they proceed on to gender reassignment (GR) via “affirmative care”. The suicide claim was dispelled in 2024 by the Finnish investigators given below, who showed that both GD and GR, when compared to controls, do not show increased suicide beyond that predicted from psychiatric problems alone (they used controls). That dispels the common claim by gender activists pushing GR: “Do you want a dead son or a live daughter?” (That’s for transitioning to female gender, but it can be reversed.)
A new paper from the same group, published in Acta Paediatrica, looks not at suicide but psychiatric “morbidity” (psychiatric problems). The study was large, controlled, and takes advantage of the fact that in Finland every doctor visit is recorded for every citizen because of the country’s national health system.
The upshot is simple: children and young people (they used subjects up to 23 years old; henceforth called “subjects”) who sought treatment for GD had significantly more severe psychiatric problems and were referred far more often for “specialist level” treatment than were controls. Those GD subjects were parsed into two groups: those who were given gender reassigment, and those who were not. The conventional wisdom is that if you have GD, then gender reassignment should significantly alleviate their dysphoria, measured by a reduced need for specialist psychiatric treatment.
The conventional wisdom was wrong: gender reassignment didn’t alleviate psychiatric compared to GD people who didn’t get reassignment. The conclusion is that gender reassignment, with its deleterious side effects, was not a good way to improve quality of life, at least measured by the need for psychiatric intervention.
Here’s how the term “gender reassignment” is used in the paper:
Medical GR interventions included masculinising/feminising hormonal treatments, chest masculinisation, and/or genital surgery (vaginoplasty/phalloplasty/metoidioplasty).
These treatments are all irreversible except that removed breasts can be restored by replacements.
Click below to access or download the pdf, or you can see the original paper online here.
As I mentioned, the sample size was large: there were 2,083 GD subjects who presented themselves for treatment, and for each of these subjects the investigators chose eight controls, four males and four females matched to the GD subjects by age and place of residence. The final controls numbered 16,643.
Here are the percentage of subjects who sought specialist-level psychiatric treatment between 2011-2019 (differences from 1996-2010 were in the same direction, but far more people who sought GD treatment had a history of specialized treatment in the later period. The authors don’t know the reason for the rise in GD-associated psychiatric difficulties, but it matches the rise in gender dysphoria in other places, including the U.S.
GD subjects
Sought specialized psychiatric treatment before the presentation for GD (“index date”): 47.9%
Sought specialized psychiatric treatment ≥2 years after the presentation for GD: 61.3%
Controls
Sought specialized psychiatric treatment before the presentation for GD (“index date”): 15.3%
Sought specialized psychiatric treatment ≥2 years after the presentation for GD: 14.2%
This shows that GD subjects, whether or not they went on to GR, initially had about three or more times the rate of psychiatric difficulties than did the controls. That is not new, as GD is generally related to psychiatric difficulties, and it’s likely that some people look for gender reassignment as a way to alleviate their gender dysphoria, or even as a way to alleviate general mental difficulties. But GD subjects in general did not in general show a lessening of psychiatric difficulties after their presentation; in fact, the rate was increased by about 13.4%.
The important figures, though, are those showing whether or not GR treatment alleviated psychiatric difficulties. After all, that is the rationale for gender-reassignment treatment, whether it be hormones or surgery. Here is Table 3 from the paper, with the last two columns being the important ones. They’re divided up by sex, and “GR-” means GD subjects not given gender reassignment, while “GR+” means GD subjects who were given gender reassignment. Click table to enlarge; I’ve put a red rectangle around the area of most importance:
This shows that GD subjects, both those who transitioned to female and those who transitioned towards male, did not have a reduction in psychiatric treatment contact (all contact, whether “specialized” or not) after their transition began or was completed. Au contraire: the psychiatric treatments went up sixfold for those transitioning to female genders and 2.5-fold for those transitioning towards male.
If you look at the third and four data columns, you can see the percentages of GD subjects who got psychiatric treatment for GD but who did not go on to reassignment. Curiously, the psychiatric treatment was more frequent in this group than in the group that went on to reassignment, but only before the data of first consultation for GD.
This difference between the third and fourth and the fifth and sixth data points on the first line is curious. But what’s important here is that there is no marked alleviation of psychiatric contacts for GD subjects who went on to reassignment. They continue to consult psychiatrists, and at about the rate of GD subjects who didn’t go on to reassignment. Again, we don’t see the mitigation of psychiatric difficulties in GD patients that go on to surgery or hormones. Since those procedures have deleterious side effects (anorgasmia and pronounced difficulties after surgery on genitals or even breasts), there is not a strong case to be made for gender reassignment of gender-dyphoric patients, at least in terms of alleviating mental illness.
The first two columns show the data for both male and female controls. Since they didn’t have consultations for GD, the “index date” for controls was given as the date that their matched GD subjects first had a consultation. And, as expected, their psychiatric visits were far less numerous than the GD subjects two years after the index date (though the low levels of consultations for GR+ subjects compared to GR-subjects before the index date is still curious, and I may have missed the authors’ explanation).
This is just a cursory interpretation I’ve made after reading the paper twice, and I may have missed some data that feed into the authors’ conclusion below. What’s clear is that GD is associated with psychiatric disorders, though it may not be causal, and that gender reassignment does not improve mental health compared to dysphoric subjects who didn’t get reassigned. All this suggests that “affirmative care” that puts GD subjects on the path to GR doesn’t, at least in this study, have the salubrious effects that are touted—as measured by the intensity of psychiatric treatment. Gender-reassigned subjects continue to suffer from mental disorders at a rate threefold to fivefold that of controls without gender dysphoria, so GR doesn’t come close to giving subjects the mental stability of controls.
The last paragraph of the paper gives what the authors see as the “Clinical Implications” of their results:
Regardless of gender, adolescents suffering from GD present with excessive psychiatric morbidity. Subsequent to medical GR, psychiatric treatment needs appear to increase. It should be noted that in some individuals, medical GR appears to be linked to deterioration in mental health. Possible mechanisms and vulnerable subgroups should be explored in future studies. The effects of medical GR and the expectations of the patient must be addressed before commencing the treatment. The considerable severe psychiatric morbidity prior to contacting the GIS, and its increase over time, suggest that for some of these adolescents, GD may be secondary to other mental health challenges. This underscores the need to thoroughly assess and appropriately treat mental disorders among those seeking GR before and after undergoing irreversible medical treatments. Psychiatric needs must be adequately met.
h/t: Christopher
It’s not hard to imagine that gender reassignment surgery causes more problems than it solves—hence the need for more psychiatric treatment. We’ll see if further research establishes causality.
Norman, I don’t think we are going to get the kind of research that would establish causality. It’s not ethical to put human subjects into an experiment where the hypothesis is that an intervention causes harm. A properly informed volunteer would decline to join the experiment because he would have no expected chance of possibly benefiting from being in it. He would refuse to be randomized and would demand to receive the standard treatment, not the one hypothesized to be harmful. He would of course be entitled to get the standard treatment (which might be “masterful inactivity”) in normal clinical practice without having to join an experiment. The researchers who believe their treatment is not beneficial but are unsure only about whether it is harmful (and not merely null), are not in a state of ethical equipoise from the point of view of “first do no harm.”
Pretty much, if a harm signal emerges from carefully done observational research that is property controlled (as well as can be done in non-randomized work, which often isn’t very well given the nature of subjective feelings), that’s as good as you’re going to get. If no confident signal of benefit had emerged from many non-randomized studies systematically reviewed together (which is where we are now with gender-“affirming” care), experimental research is unlikely to rescue the treatment and, deus ex machina, find it more beneficial than harmful. At least that’s not the ethical way to bet with human welfare.
The PATHWAYS Trial in the UK has been paused over precisely these concerns about equipoise (as well as other methodologic faults which degrade its ability to discover the truth. I’m focusing here on the ethical concerns.)
Thanks for this post. I have seen references to this article in the sex realist space and I’m glad to see it here with commentary. One item that I think raises pointed critical commentary by many women and medical people: “removed breasts can be restored by replacements.”
An example of criticism, quoted from R.T. Bosshardt, MD:
“Advocates of “gender-affirming” care often insist that this damage is reversible. Asked about girls who later regret their decision to have their breasts removed, Joanna Olson-Kennedy, a pediatrician and prominent advocate of transgender medicine stated, “If you want breasts at a later point in your life, you can go and get them!”
Her comments are unacceptable and dangerously naive. If she is telling patients that they can easily “go and get” breasts after a mastectomy—that breast reconstruction is a low-risk procedure—she is misleading them. Breast reconstruction is a major surgery. It requires inserting implants and/or shifting skin, fat, and, sometimes, muscle, from one area of the body to the chest. Some procedures leave two distinct surgical sites, both with potential complications. In the worst case, reconstruction can have catastrophic consequences, such as failed reconstruction or even death. Even if the procedure avoids these harms, the patient’s reconstructed breasts will never look or feel normal.”
I’m not a medical doctor (so correct me if I’m wrong here):
I believe that if a woman has a double mastectomy, she will use the ability to breastfeed a child. Later breast reconstruction cannot restore that function. I think nipple sensitivity also cannot be restored through breast reconstruction.
This study from Finland is very valuable. I hope that we willl see out of England a study that tells us what happened to the pediatric patients of the Gender Identity Development Service clinic in London who underwent gender-affirming treatments (see Hannah Barnes’ book Time to Think). And if I thought praying worked, I would pray that the planned puberty blocker trial in England will not go ahead as long as this follow-up study has not been done – since the puberty blocker trial would, with certainty, destroy the fertility and degrade the sexual functioning of the trial participants.
I the second sentence of my comment it should be:
I didn’t say they could be restored without issues (I went out with a woman who underwent the procedure, and it was long and painful). Nor did I say they’d be functional in the same way real breasts are: they provide neither milk nor sensation. But thanks for the explanation.
The procedure or going out with her?
The procedure, of course!
Is there any solid evidence for everyone having a “gender identity”? It seems like everything flows from that concept, but I have never seen anything other than assertions that everyone has one and everyone, even small children, can determine what it is through introspection.
Leor Sapir, has a recent, short (4 minutes long) and incisive video on gender identity – what that term means:
https://x.com/LeorSapir/status/2042613377143321061
Bottom line: if you follow WPATH (World Professional Association for Transgender Healthcare), and you discard circular reasoning and contradictory statements, gender identity means “how a person relates to gender stereotypes,” where gender has the meaning of social expectations about how member of a specific sex behave (or ought to behave) in a given society.
Very useful. Thanks for posting the link. I should also thank our host for posting on this research.
Indeed, I have to say that my “gender identity” is not something I ever think about. Maybe I don’t even have one, though I am a married male. Maybe that’s all it is – a descriptor of one’s social status on certain dimensions. A descriptor that some people get wrong for whatever reasons.
This is hardly surprising. What is surprising is that so many members of the medical community bought into the idea of major surgery and/or life-changing hormonal treatment during childhood or adolescence as a treatment, often without extensive psychiatric/psychological counseling. I would call this serious malpractice—one does not do major surgery without investigating the problem in a thorough manner.
And any physician who believes that mastectomies, (especially in adolescent patients) are “easily reversed” never did his/her homework in medical school, and/or allows their knowledge to be corrupted by ideology.
Can the discovery and development of “affirmative care” be traced to the work of a single genius? If so, that individual surely belongs in the company of Antonio Egas Moniz, who received a 1949 Nobel Prize for devising the prefrontal lobotomy treatment for “certain cases of mental disorder”.
I’m a bit chagrined that in all of hundreds of billions of dollars our country spends on research, we don’t have research that adds to or disputes this Norwegian research on pediatric gender dysphoric medical interventions. We have a decade or more of an accelerated demand for pediatric gender affirming medical interventions, societal accommodation of new rights and frictions where those rights negatively affect the rights of others and governmental interventions between parents and emotionally suffering gender dysphoric children but we lack basic research on how effective these interventions are for the children we are trying to help. That lack may be telling us something important about ourselves and our civic, academic and research cultures. If so, do we like what we see?
Sorry, correction: Finnish study.
At the risk of over-commenting, I cannot resist noting a peculiar feature of life in the groves of academe.
Suppose a university electrician publicly based his work on the fantasy that phones, recording devices, lights, and electric outlets each have an ineffable “identity” of their own, an identity not subject to empirical evidence. The University would no doubt dismiss this employee in short order, and would also fire car-pool mechanics, janitors, and other non-academic staff who harbored similar fantasies. But a focus on objective reality is evidently not required of academics. Is this what is meant by the phrase “academic freedom”?
I object to the generalization. I am pretty sure, a Chemist that insists hazardous properties of carcinogens are merely social constructs and dumps them into the sink has a very short career.
If one is interested in the effect of medical gender reassignment (GR+) on psychiatric morbidity (as indicated by referral to a psychiatrist), the appropriate control group is the group with gender dysphoria that did not receive medical gender reassignment (GR–). The community controls are irrelevant.
Furthermore, since this is an observational study, one cannot assume that the GR+ group and GR– groups are comparable. Indeed, there is glaring evidence that they are not. As Table 3 shows, the GR+ group had far less pre-treatment psychiatric care than the GR– group. But that is likely not the only way the groups differed.
Subjects entered the study over a 24-year period; the last subjects to enter the study were a full generation apart from the first subjects. There is little doubt that psychiatric referral, gender treatment, and, likely, young people’s psychiatric health, changed over that period. Moreover, age at study entry, and pre-gender-treatment psychiatric care itself predict post-gender-treatment psychiatric care. All of these variables (age, year of study entry, and psychiatric history) are confounding variables that must be controlled before a meaningful comparison of the effect of medical gender treatment on psychiatric morbidity can be made.
The authors never make this comparison (after control of confounders) explicitly. But they do run a model that controls for these variables, and we can make the comparison ourselves from the results they present in Table 4 or 5 (they show essentially the same thing).
Using the numbers from Table 4 (the last column labeled “HR”), the relative risk of post-gender-treatment psychiatric treatment for GR+ vs. GR– was:
For biological males: 6.1 / 4.8 = 1.27 or, in other words, 27% higher for medical gender treatment.
For biological females: 4.9 / 4.7 = 1.04 or, in other words, 4% higher for medical gender treatment (which would not be statistically significant).
These numbers are still not favorable for medical gender treatment, but they paint a much less dire picture than the confounded numbers from Table 3, which erroneously suggest a 6-fold and 2.5-fold increase in post-gender-treatment psychiatric treatment in biological boys and girls, respectively, who underwent medical GR.
First, to answer PCC(E)’s query, “. . . though the low levels of consultations for GR+ subjects compared to GR- subjects before the index date is still curious, . . .”
An adminstrative database can’t reveal why a patient referred to a clinic for gender dysphoria wouldn’t get GR. One contraindication to offering it, though, is severe psychiatric disturbance. The 3rd & 4th columns show that subjects who didn’t get GR were indeed more likely to have had psychiatric consultation before referral than those who did, a proxy for poorer mental health. Likely the clinic doctors screened them out as ineligible for GR. (Tordoff also found substantial numbers of gender clinic patients never got GR, and they, too, had much poorer mental health.)
This is relevant to Jay Tanzman’s criticism of the study. It’s the reason the GR- subjects with GD would not be appropriate controls for the GR+s. In a randomized controlled trial of GR, you would indeed compare later use of psychiatry in GR+ with that in GR-. But you couldn’t randomize them all in the first place if the GR intervention was contraindicated in any of them. That would be ethically improper as well as scientifically unsound. A trial has to screen all the volunteers and exclude, before randomization, those who you already know shouldn’t get the treatment (e.g., severe psychiatric disease.) You can’t do that in observational research: the patients have already been treated, or not, according to clinical judgement. If the doctors had given GR to all their patients with or without severe psych disease thinking it was good for everyone, then you would try to control for pre-extant psych treatment. But in this study they did exclude the most disturbed, so there is nothing to control for.
The population controls do tell us that the subjects with GD had psych trouble not much more frequently than the age-matched general population before they got GR. The clinics are treating only the best risks; nonetheless they needed psych care two years later. Because this is a before-after study, the population of treated subjects (GR+) can serve as its own control to look for an amelioration of mental health troubles after two years of GR (whether causal or not.) In both MtF and FtM they found the opposite. Unless there is other confounding not detected, this is a signal of harm from GR.
Do you know of a writeup of this or a similar ethics+sampling example that is at an accessible level for above-average high school seniors? I may have an opportunity to use it in a “stochastics” class. Sampling bias in general is a topic I want to cover, and including ethical issues in a maths example strikes me as a Good Thing.