In Italy there persists an obstinate silence on pharmacological treatments for minors with gender dysphoria (puberty blockers, cross-sex hormones, 'gender reassignment' surgery) according to the protocol of so-called gender affirmative therapy. It is not possible to know how many minors have been treated or are currently undergoing treatment, in how many and which centres they are treated and with what 'success' (or failure) rates. While in the whole western world the debate has been open for some time and in some countries it has led to the abandonment of these 'therapeutic' paths, in Italy we are still at the no-debate stage, every attempt to access certain data clashes with a rubber wall and the mainstream press and TV continue their propaganda work, isolating and stigmatising as transphobic every critical voice. It is precisely for this reason that testimonies such as that of the Finnish adolescent psychiatrist Riittakerttu Kaltiala, already a pioneer of these treatments and now more than convinced of their harmfulness and uselessness, should be considered with the utmost attention.
Dr. Riittakerttu Kaltiala, 58 years old, is head of the department of adolescent psychiatry at the University Hospital of Tampere, Finland. He treats patients, teaches medical students and conducts research in his field. He has published more than 230 scientific articles.
In 2011, Dr Kaltiala was given a new responsibility. She was to supervise the establishment of a gender identity service for minors. As a result, he became one of the first doctors in the world to run a clinic dedicated to the treatment of young people with gender distress. Since then, he has personally participated in the assessment of more than 500 adolescents. Today Kaltiala, Having been a pioneer, she is at the forefront against gender affirmative therapy for minors based on puberty blocking drugs and cross-sex hormones.
Earlier this year, the Free Press published the report by Jamie Reed, former head of the issue at Washington University's Transgender Centre at St. Louis Children's Hospital. The author recounted her growing alarm over the effects of child transition treatments. Dr Kaltiala's testimony reinforces this alarm. Here it is.
"At the beginning of my medical studies I knew I wanted to become a psychiatrist. I decided to specialising in the care of adolescents because I was fascinated by the process through which young people actively explore who they are and seek their role in the world. My patients' adult lives are still ahead of them, so helping a young person who is on a destructive path can make a huge difference to their future. Moreover, individual therapeutic work gives great satisfaction.
In the last decade there has been a dramatic development in my field. A new protocol providing for the gender, social and medical transition of children and adolescents with gender dysphoria, i.e. a discordance between one's biological sex and the internal feeling of being of a different gender.
This condition had been described for a long time but it is the 1950s that are considered the beginning of the modern era of transgender medicine. Throughout the 20th century and into the 21st a small number of mostly adult men, with lifelong gender discomfort, were treated with oestrogen and surgery to help them live as women. Then, In recent years, new research has come in on the possibility of successful medical, especially hormonal, transition in minors.
One of the motivations of the doctors who supervised these treatments was to prevent young people from having to face the difficulties encountered by adult men in trying to convincingly appear as women. The most important advocate of youth transition a group of Dutch doctors. In 2011 they published a revolutionary document which stated that if young people with gender dysphoria were able to prevent their natural puberty by blocking it with drugs, followed by opposite-sex hormones, they could have started living their transgender lives earlier and more credibly.
Thus was born the "Dutch protocol'. The patient population described by the Dutch doctors consisted of a small number of young people - almost all males - who insisted on being female from an early age. The carefully selected patients, apart from their gender discomfort were mentally healthy and high-functioning. Dutch doctors reported that after early intervention these young people lived fully as members of the opposite sex. The protocol was quickly adopted internationally as the standard treatment in this new field of paediatric gender medicine.
At the same time, a activist movement who declared that gender transition was not just a medical procedure, but a human right. This movement has taken on an increasingly high profile and activists' agenda controlled media coverage of these issues. Proponents of the transition have also realised the power of the emerging technology of the social media.
In response to all this In Finland, the Ministry of Social Affairs and Health wanted to create a national paediatric gender programme. The task was given to the two hospitals that already hosted gender identity services for adults. In 2011 my department was commissioned to open this new service and I, as the head of psychiatry, became responsible for it.
However, I posed myself questions. We were told to intervene on healthy, functioning bodies simply on the basis of a young person's changing feelings about gender. Adolescence is a complex period in which young people consolidate their personality, explore sexual feelings and become independent of their parents. The realisation of identity is the result of successful adolescent development, not its starting point.
In our hospital we used to discuss a lot with bioethicists. I was concerned that gender transition would interrupt and disturb this crucial phase of psychological and physical development. In the end we got a declaration by a national health ethics committee which suggested undertaking this new intervention with caution.
We are a country of 5.5 million inhabitants with a national health care system, and since we needed a second opinion to change identity documents and proceed to gender surgery, I personally met and evaluated most of the young patients from both clinics who were requesting the transition: to date, more than 500 young people. The approval of the transition was not automatic. In the first years, our psychiatric department accepted the transition for about half of the patients. In recent years, this percentage has dropped to about 20%.
When the service started in 2011 there were many surprises. Patients not only came, they came in droves. Across the western world, the number of children with gender dysphoria was skyrocketing.
But those who arrived were nothing like the patients described by the Dutch. We expected a small number of boys who insisted on declaring themselves female. Instead, 90% of our patients were girls, mostly aged between 15 and 17, and instead of being high-functioning the vast majority had severe psychiatric conditions.
Some came from families with multiple psychosocial problems. Most of them had had a difficult early childhood, marked by developmental difficulties such as anger outbursts and social isolation. Many had problems at school. They were commonly bullied, but not with regard to their gender presentation. They felt lonely and isolated. Some no longer went to school and spent all their time alone in their room. They suffered from depression and anxiety, some had eating disorders, many were self-defeating, some had had psychotic episodes. Many of them - many - manifested autism spectrum disorders.
It was surprising that few had manifested gender dysphoria before the improvent announcement during adolescence. They came to us because their parents, usually only their mothers, had been informed by some member of aLGBT organisation that their daughter's real problem was gender identity, or because their daughter had seen something online about the benefits of transition.
Already during the early years of the clinic gender medicine was rapidly becoming politicised. Few questioned what the activists, among whom were medical professionals, were saying. And they were saying remarkable things. They claimed that not only would feelings of gender anguish immediately disappear if young people started the medical transition, but also that all their mental health problems would be alleviated by these interventions. Of course there is no mechanism by which high doses of hormones resolve autism or any other underlying mental health condition.
Since what the Dutch had described differed so drastically from what I saw in our clinic, I thought that maybe there was something unusual about our patient population. So I started talking about our observations with a network of professionals in Europe. I found that they all had to deal with a similar caseload of girls with multiple psychiatric problems. Colleagues from different countries were also confused by this. Many said it was a relief to know that their experience was not unique.
But no one said anything publicly. We felt a strong pressure to provide what was supposed to be a wonderful new treatment. I sensed within myself, and saw in others, a crisis of confidence. People stopped trusting their own observations of what was happening. We had doubts about our training, our clinical experience and our ability to read and produce scientific evidence.
Shortly after our hospital started offering hormone interventions for these patients, we started to see that the promised miracle was not taking place. In fact, it was exactly the opposite.
The young people we were looking after were not thriving. On the contrary, their lives deteriorated. We asked ourselves, "What happens?" There was no hint in the studies that this could happen. Sometimes the young people insisted that their lives had improved and that they were happier. But as a doctor I could see that they were getting worse. They withdrew from all social activities. They did not make friends. They did not go to school. We continued networking with colleagues from different countries who said they were seeing the same things.
I became so concerned that I undertook a study with my Finnish colleagues to describe our patients. We methodically examined the medical records of those who had been treated at the clinic in the first two years and reported their problems - one of them was mute - and their differences from the Dutch patients. For example, more than a quarter of our patients suffered from autism spectrum disorders. Our study was published in 2015 and I believe it was the first publication in a journal by a gender clinician to raise serious doubts about this new treatment.
I knew that others were making the same observations in their clinics and hoped that my article would spark a discussion about their concerns: this is how medicine corrects itself. But our field, instead of recognising the problems we had described, he became more involved in the expansion of these treatments.
In the United States, the first paediatric gender clinic was opened in Boston in 2007. Fifteen years later, there were more than 100 such clinics. As US protocols developed, fewer restrictions were placed on the transition. A Reuters investigation found that some US clinics approve hormone treatments at a minor's first visit. The United States has pioneered a new standard of treatment, called "gender-affirming care, which urged doctors to simply accept the child's assertion of a trans identity and to stop being 'gatekeepers' who raised doubts about transition.
Around 2015 in addition to psychiatric patients a new type of patients started arriving at our clinic . We started to see groups of teenage girls, also usually between 15 and 17 years old, from the same towns or even the same schools, telling the same life stories and anecdotes about their childhood, including the sudden realisation of being transgender despite having no previous history of dysphoria. We realised that were networking and exchanging information on how to talk to us. And so we had our first experience of social contagion related to gender dysphoria. This was also happening in paediatric gender clinics around the world, and again health workers were silent.
I understood the reasons for this silence. Anyone, including doctors, researchers, academics and writers, who raised concerns about the growing power of gender activists and the effects of the medical transition of young people was subjected to organised defamation campaigns and threats to their careers.
In 2016, due to several years of growing concern about the harm of transition on vulnerable young patients, the two Finnish paediatric gender services have changed their protocols. Now, if young people had other more pressing problems than gender dysphoria that needed to be addressed, we would promptly refer them to a more appropriate treatment such as psychiatric counselling, rather than continuing the assessment of gender identity.
Activists, politicians and the media have lobbied strongly against this approach. The Finnish press published stories of young people dissatisfied with their decision, portraying them as victims of gender clinics that forced them to put their lives on hold. A Finnish medical journal published an article entitled 'Why don't trans teenagers get their blockers? which took the perspective of the dissatisfied activists.
But I was taught that medical treatment must be based on medical evidence and that medicine must constantly correct itself. When you are a doctor who sees that something is not working, it is your duty to organise yourself, do research, inform your colleagues, inform the public and discontinue that treatment.
The Finnish national health system gives us the opportunity to investigate medical practices and establish new guidelines. In 2015 I personally asked a national body, called the Council for Choices in Health Care (COHERE), to create national guidelines for the treatment of gender dysphoria in minors. In 2018, I renewed this request with colleagues, which was granted. COHERE commissioned a systematic review of evidence to assess the reliability of the current medical literature on youth transition.
At the same time, eight years after the opening of the gender paediatric clinic, some former patients started coming back to tell us that they regretted their transition. Some, called 'detrans', wished to return to their birth sex.. This was another type of patient who was not expected. Instead, the authors of the Dutch protocol stated that regret rates were minimal.
But the foundations on which the Dutch protocol was based are crumbling. The researchers showed that their data had some serious problems and that they had not included many people in their follow-up who might have regretted the transition or changed their minds. One of the patients had died due to complications from the genital transition surgery.
In the world of paediatric gender medicine, the statistic is often reported that only 1% or less of young people who make the transition subsequently detransition. But even studies claiming this are based on biased questions, inadequate samples and short time frames. I believe that repentance is much more widespread. For example, a new study shows that almost 30% of the patients in the sample stop following the hormone prescription within four years.
Usually it takes several years before the impact of the transition is fully felt. It is the time when young people who have entered adulthood are confronted with the meaning of a possible sterility, impairment of sexual function, great difficulty in finding romantic partners.
It is devastating to talk to patients who say they were naive and misled about what the transition would mean for them, and who now feel that it was a terrible mistake. Mostly these patients tell me that they were so convinced they had to make the transition that they withheld information or lied during the evaluation process.
I continued to research the topic and in 2018, together with colleagues, published another article investigating the origin of the growing number of gender dysphoric young people. But we found no answers as to why this phenomenon occurs or what to do about it. In our study, we noticed a fact that is generally ignored by gender activists: in the vast majority of cases of children with gender dysphoria - about 80% - the dysphoria resolves itself if they are allowed to go through natural puberty. Often these children realise that they are gay.
In June 2020, an important event happened. Finland's national medical body, COHERE, has published its conclusions and recommendations on the gender transition of young people. The body concluded that The studies propagating the success of the 'gender-affirming' model were biased and unreliable, in some cases systematically.
The authors wrote: "In light of the available evidence, thehe gender reassignment of minors is an experimental practice'. The report states that young patients who desire gender transition should be educated about the "reality of a lifelong commitment to medical treatment, the permanence of the effects, and the possible negative physical and mental consequences of the treatments". The report warns that young people, whose brains are still maturing, do not have the capacity to 'adequately assess the consequences' of decisions they will have to live with for the 'rest of their lives'.
COHERE also recognised the dangers of administering hormone treatments to young people with severe mental illness. The authors concluded that, for all these reasons, gender transition was to be postponed 'until adulthood'.
It took a long time, but I was redeemed.
Fortunately, Finland is not alone. After similar reviews, the UK and Sweden came to similar conclusions. And many other countries with national health systems are re-evaluating their position of 'gender affirmation'.
I felt more and more obliged towards patients, medicine and the truth, to speak out against the widespread transition of children with gender problems outside Finland. I am particularly concerned about the American medical societies, who continue to assert that children know their 'authentic' selves and that a child who declares a transgender identity should be supported and referred for treatment. (In recent years, 'trans' identity has evolved to include more young people claiming to be 'non-binary', i.e. who feel they do not belong to either sex, and other gender variations).
Medical organisations should transcend politics in favour of standards that protect patients. However, In the US, these groups - including the American Academy of Paediatrics - are actively hostile to the message that I and my colleagues are urging.
I tried to address the growing international concerns about gender transition in childhood at this year's annual conference of the American Academy of Child and Adolescent Psychiatry. But the two proposed panels were rejected by the academy. This is very worrying. Science does not progress through silence. Doctors who refuse to consider the evidence presented by critics put patient safety at risk.
I am also disturbed by the way gender doctors routinely warn American parents that there is a enormously high risk of suicide if they hinder their children's transition. The death of any young person is a tragedy, but careful research shows that suicide is very rare. It is dishonest and extremely immoral to put pressure on parents to endorse gender medicalisation by exaggerating the risk of suicide.
This year the Endocrinological Society of the United States reiterated its support for hormone transition for young people. The company president wrote in a letter to the Wall Street Journal that such treatment is 'life-saving' and 'reduces the risk of suicide'. I have co-authored a letter of reply, signed by 20 doctors from nine countries, refuting his claim. We wrote that 'every systematic review of the evidence to date, including one published in the Journal of the Endocrine Society, has offered evidence with a low or very low certainty of the mental health benefits of hormonal interventions for minors".
Medicine, unfortunately, is not immune to the dangerous groupthink which results in harm to the patient. What is happening to dysphoric children reminds me of the 'recovered memory' craze of the 1980s and 1990s. At that time, many women in distress came to believe false memories, often suggested by their therapists, of non-existent sexual abuse by their fathers or other family members. According to the therapists, this abuse explained everything that was wrong in their patients' lives. Families were destroyed and some people were prosecuted on the basis of fabricated claims. It all ended when therapists, journalists and lawyers investigated and denounced what was happening.
We must learn from these scandals. Because like recovered memory, gender transition got out of hand. When medical professionals start claiming to have a one-size-fits-all answer or a cure for all of life's pains, it should be a warning to all of us that something went very wrong'.
by Mara Accettura, original article here
