'Rubbish'—Finland's Top Pediatric Gender Psychiatrist Derides Exposé Claiming Her Clinic Provided Shoddy, Cruel Care
The prime target of journalist Evan Urquhart's scathing reporting about Finland's pediatric gender clinics characterizes his article as "intentional defamation."
Finland is often a target of Western transgender activists’ ire, due to the nation’s particularly restrictive policies on prescribing puberty blockers and cross-sex hormones to treat gender dysphoria in young people. The Nordic bête noire for such activists is Dr. Riittakerttu Kaltiala, chief psychiatrist at the Tampere University Hospital Department of Adolescent Psychiatry in Finland.
In 2011, Dr. Kaltiala was tasked with launching and leading one of Finland’s two pediatric gender clinics. There, she and her colleagues sought to follow what’s known as the Dutch model of care for children with gender dysphoria. Researchers in the Netherlands had demonstrated promising results by carefully assembling a cohort of children with severe, ongoing gender dysphoria and medically guiding them into a cross-sex puberty.
As the 2010s progressed, Dr. Kaltiala became increasingly convinced that gender-reassignment, as it’s known in Finland, was not actually helping the population of young people who inundated the clinics. She found it remarkable how different from the original Dutch cohort these youths were. They tended to have a strikingly high level of psychiatric comorbidities, to have gender dysphoria that started in adolescence rather than early childhood, and were more likely to be natal females.
Dr. Kaltiala began to publish papers that illustrated her concerns. Ultimately, Finland conducted a systematic literature review of the evidence behind such treatment and found it wanting and inconclusive. Accordingly, in 2020, the nation’s health authorities set sharp restrictions on the ability for gender-distressed minors to access puberty blockers and cross-sex hormones. And in October 2023, Dr. Kaltiala went so far as to publish in Bari Weiss’ The Free Press a scathing rebuke of medically transitioning minors: ‘Gender-Affirming Care Is Dangerous. I Know Because I Helped Pioneer It.’
“The young people we were treating were not thriving. Instead, their lives were deteriorating,” Dr. Kaltiala wrote.
On July 30, American journalist Evan Urquhart published on his independent news site, Assigned Media, a scathing account of a handful of young Finnish transgender people who had sought care for gender dysphoria through the nation’s gender-clinic system. Cowritten with the Finnish writer Esa Kalliomäki, the article boldly asserted:
“Former patients say rude staff, uncomfortable questions about masturbation, years of assessment with no therapeutic support, and abrupt dismissals without any treatment made the experience a living hell.”
By Urquhart’s ghoulish characterization, the Finnish pediatric gender clinics were established not to provide gender-dysphoric young people what these youths were certain would benefit them, namely gender-transition treatment. Rather, the care providers, the article asserted, led these highly distressed and increasingly desperate young people through an uncomfortable and protracted limbo.
The article’s centerpiece, meant to inspire disgust and dismay, was a collection of accounts of clinicians asking patients probing questions about masturbation and, in one case, admonishing the young person to go home and masturbate. (In Finnish, masturbation is known as “solo sex.”)
Urquhart’s indictment of Dr. Kaltiala in particular hinged on what he presented as a smoking gun: an essay the psychiatrist wrote about pediatric gender medicine in 2011 for a Finnish magazine. (It was her half of a debate on the subject with another author.) This essay, Urquhart asserted, proved that Dr. Kaltiala “vehemently argued against Finland providing any access to gender transition to minors.” To back his point, he linked to a previous article he published May 22 that also made reference to Dr. Kaltiala’s essay from 13 years ago. In his piece from the spring, Urquhart wrote that the essay proved that Dr. Kaltiala harbored “longstanding opposition to medical transition for youth.”
He provided this screenshot of the essay:
But Urquhart did not provide a translation of the essay, nor did he quote from it.
I obtained a translation myself. I found that Dr. Kaltialia did indeed express strong reservations about the potential benefits of a medical gender-transition for young people. However, she explicitly remained open to the possibility.
She stated:
“Adolescent identity development is in process and identity confusion is common among young patients of psychiatric clinics. The risk of iatrogenic damage [when a medical treatment causes harm] to youth when rushing the treatment of their gender identity disorder is great. However, if the trans youth has good mental health and a stable and supportive family life, it is shown that they will benefit from blocking puberty and hormonal treatment to change the features of their gender.”
This is evidence of Dr. Kaltiala weighing the known harms of providing such treatment against findings that some children will benefit from them. In her statement, she is indeed leaving the door open for some children to receive such drugs.
Dr. Kaltiala did not provide any comment for Urquhart’s article. I interviewed her myself earlier this year for an article I wrote for the New York Post about her study that found that pediatric gender-transition treatment was not independently associated with a statistically significant difference in the suicide death rate in young people. (The paper has many detractors. Others have pushed back against their criticisms.) So I reached out to her to see if she would discuss Urquhart’s article with me.
She agreed.
Below is a Q&A between Dr. Kaltiala and me about Urquhart’s article, conducted over email. My questions are in bold, her responses are in plain text.
Urquhart has portrayed the Finnish pediatric gender clinic as abrupt, creepy and uncaring. How do you respond to this portrayal?
That is intentional defamation and deserves no further discussion.
The article puts particular emphasis on the notion that it is inappropriate to discuss masturbation with young gender dysphoric patients, or at the very least to instruct or encourage them to masturbate. How do you respond to such criticism?
Discussing sexual development is an important facet of any comprehensive assessment in adolescent medicine. During adolescent years, sexual behaviours gradually develop towards adult-type, genitally intimate sexuality. In an adolescent-centered discussion of sexuality, psycho-education can be provided as appears necessary, for example that solo sex is ok and safe. Adolescents presenting with feelings of gender dysphoria are often confused about their sexuality and afraid of it. It is good to know what sexual feelings can be before possibly opting out of them. Medical gender reassignment interventions may permanently damage sexual functioning.
(Above is a video of Dr. Marci Bowers, a gender-affirmation surgeon and the head of the World Professional Association for Transgender Health, discussing the importance of discussing masturbation with young transgender patients.)
At least some of the minor patients described in the article appeared to have attended a Finnish clinic after the nation began restricting access to puberty blockers and cross-sex hormones for gender dysphoric minors in 2020. Would you say that Urquhart has notably left out this detail?
Any medical interventions always have to be considered individually based on adequate assessment of the patient in question. While in Finland we initially adopted the Dutch approach, there was never such a guideline Finland that would have advised rapid and liberal use of puberty blockers. Also, most of the adolescents ever admitted to the nationally centralized gender identity assessments have already been in their mid-teens with adolescent-onset gender dysphoria, and thus beyond the possibility to prevent the development of sex characteristics, as was the idea of the “Dutch model” with puberty blockers. Young people for whom GnRH analogues could be used to meaningfully block pubertal development have always been only a few. Any hormonal interventions have always been only considered after comprehensive case-by-case assessment and as appropriate given the young person’s pubertal status.
(Note that on Aug. 19, Dr. Kaltiala and her colleagues published a paper that found that across the years, 7.9% of Finnish people of all ages who received gender-reassignment treatment with cross-sex hormones ultimately stopped taking them. The discontinuation rate was higher in more recent years. The authors speculated that the rate of discontinuation of treatment was relatively low—an American V.A. study found a 30% discontinuation rate—because of the high level of so-called gatekeeping in the country’s health services before gender-reassignment treatment is prescribed.)
Soon after starting the gender services, we informed the health authorities and the medical community about our observations that the patients were not similar as described in the Dutch model, and later that the outcomes regarding mental health and functioning were not good. Therefore, national guidelines were needed. The research done for the guideline by independent experts resulted in the conclusion that the evidence base of early physical intervention was not solid and now we are even more judicious in our assessment of young people, as most do not appear to benefit from the hormonal treatment approach .
Urquhart has claimed that you were a “committed skeptic” who had “vehemently argued” in a 2011 magazine article “against Finland providing any access to gender transition to minors.” I had that magazine article translated, and my understanding of it was that you were saying that there were indeed some children who apparently would benefit from such treatment. What is your response to Urquhart’s claims about your position about gender-reassignment treatment when you opened the clinic in 2011?
Before 2010, this topic was not discussed in Finland. Gender reassignment could be considered for adults, and we were content that identity consolidation is the outcome of adolescent development. News about the Dutch model and the suggestion that physical interventions on identity basis would be justified even from early adolescence felt revolutionary and courageous. In that “debate piece” from 2011 media wanted to present opposing views as is often your style in all media! I felt that adult psychiatrists and politically motivated actors in the debate did not have appropriate understanding of adolescent development with its vulnerabilities, uncertainties and still-open trajectory options, and I expressed my belief. However, when tasked with setting up the national clinic, I and my team, in collaboration with the other team, set our doubts aside and prepared to act according to new evidence. As we now know, my initial concerns have unfortunately were proven to be largely appropriate, and this evidence of benefits was inadequate and untrustworthy.
Did you testify in favor of banning gender-reassignment treatment for children in Florida?
I was asked to share my expertise with the Florida Board of Medicine as it was exploring whether and how to regulate the practice of youth gender medicine. I shared our experience from the Finnish gender services, specific to the complexities in the patient mix and the mental health outcomes of hormonally-treated youth. My understanding is that many experts were invited, including several American Medical Associations.
Were you a member of the advisory board for the British Cass Review of pediatric gender medicine?
Yes, and I really wonder why is everybody in the USA asking for that. Are not external advisory boards a commonplace in such comprehensive projects of major importance?
Urquhart claims that while your research in Finland shows that gender-reassignment treatment is not benefitting minors, “research from other countries shows clear benefits of transition for both young people and adults.” How do you respond to that claim?
COHERE Finland obtained a state of the art systematic review about this in 2019, and the experts did not find the evidence for Urquhart claims. I have personally reviewed all materials I could find to evaluate the claimed benefits for reduction of mental health problems and prevention of suicide as well as improvement of functioning or quality of life for a webinar organized by the ISSM [the International Society for Sexual Medicine] and WPATH [the World Professional Association for Transgender Health] in 2021 and concluded that it has not been shown that severe mental disorders would remit or functioning or quality of life improve with hormonal interventions for GD [gender dysphoria] during developmental years, and that no research could actually say anything about suicide. The presentation was repeated (updated as appropriate) in the EPATH [WPATH’s European arm] and ESPE [European Society for Pediatric Oncology] congresses later that year. Thereafter Swedish authorities, Cass Review team and some other bodies have repeated and updated such systematic reviews without finding evidence for the claimed benefits for mental health and functioning. Instead, understanding of risks to bone health, sexual functioning and cognitive development are mounting. The WPATH commissioned systematic review did not find the evidence for those claimed positive effects, and admitted, in the lines of my team’s subsequent research regarding completed suicide (which is rare), that it has not been shown that hormonal interventions would reduce suicidality.
Urquart claims that his reporting shows that Finland is doing a poor job of caring for gender-dysphoric minors, and that’s why your research shows poor outcomes. How do you respond to that claim?
Rubbish.
How do you respond to Urquhart’s claim that “there’s no benefit in putting an adolescent through the humiliation of being asked to describe how they masturbate to a strange adult” and to the claim by A. J. Eckert, an Attending Physician at the Center for Transyouth Health and Development at Children’s Hospital, Los Angeles, that this is “gross!”?
If Urquhart thinks that discussing sexual development with young people is “gross,” then this individual [Eckert], whoever they are, obviously have no business commenting on the practice of youth gender medicine. Sexuality is a part of any comprehensive assessment in adolescent medicine, and age-appropriate conversations about sexual development are critical for young people who are in the process of trying to assent or consent to the likely loss of sexual function.
How do you respond to the claim that “the process was designed to break” the patients “and encourage them to give up” on obtaining gender-reassignment treatment?
Medical gender reassignment is irreversible. The purpose is to ensure, as far as possible, that medical gender reassignment is optimal and timely for the young person in question, and that they and their parents as fully as possible realistically understand the possible benefits, risks and uncertainties related to the decisions to be taken, and are able to consent. Informed consent is much more that a signature on a form, despite WPATH insisting that such a model of care is sufficient. A slow and careful process is essential for true informed consent.
Are you able to provide me with any figures of how many minors have received puberty blockers and cross-sex hormones in Finland since 2011? What were the median ages at which minors started these respective drug
About 400 young people who have first contacted gender identity services before age of legal adulthood have had the opportunity to opt for medical gender reassignment, but I cannot easily provide exact information of what treatments they possibly have started and at what age exactly. The mean age at first contacting gender identity services has been about 16 years, thus the actual initiation of medical treatments has often likely been after age 18.
(Note that when I interviewed her about her suicide study in February, Dr. Kaltiala said that “many” started cross-sex hormones before age 18, but also did not provide exact figures.)
Why have such figures not been published? (Published papers tend to lump minors in with young adults.)
In our few register-based studies we have lumped minors with late adolescents in order to have time series from 1996, to increase statistical power. 18-22-year olds are in the adolescent development process anyway.
Why does Finnish policy, as I understand it and as the Urquhart article demonstrates, restrict minors from receiving gender-transition treatment if they have psychiatric comorbidities?
Not automatically, but severe psychiatric disorders most often complicate and delay identity formation and compromise the safety of identity based medical treatment decisions. All treatment decisions are made individually.
I am an independent journalist, specializing in science and health care coverage. I contribute to The New York Times, The Guardian, NBC News and The New York Sun. I have also written for the Washington Post, The Atlantic, The Nation, Thomson Reuters Foundation, New York, The Marshall Project and PBS.
Follow me on Twitter: @benryanwriter.
Visit my website: benryan.net
So the group that wants to remove reproductive organs, believes discussing sexual habits is a bridge too far?
These must be the same folks that get married without discussing their desire to have children with their partner, to only get divorced shortly after when inevitably learning the truth. Never considered they were just avoiding these questions of ultimate importance because they are too "gross". I just thought they were idiots.
"to the claim by A. J. Eckert, an Attending Physician at the Center for Transyouth Health and Development at Children’s Hospital, Los Angeles, that this is “gross!”"
Lots of medicine is gross. If you can't deal with gross stuff, don't be a doctor.