Finland. Children with gender dysphoria, new guidelines: more psychological help, less hormones

Psychological therapies, for years stigmatised as conversion therapies, are once again the first option for girls with gender dysphoria in Finland. Hormones for minors have come to a halt in many western countries. And in Italy?
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Many of the pioneering countries in the hormone treatment of children to start the transition are revising their guidelines. In Sweden, under-16s can no longer be treated with drugs, and in the UK, after the landmark Keira Bell ruling -see here- In Finland, psychotherapeutic treatments are again being favoured, with hormone therapy being used only as a last resort. In Italy, the use of puberty blockers on children is allowed with a simple medical diagnosis and without the intervention of a court. Data on the number of minors treated are not yet known. Presumably, as in the rest of western countries, it is mainly girls -7-8 cases out of 10- who identify themselves as boys.

There are many differences in the Finnish guidelines compared to how Canadian clinics are currently treating gender dysphoria. In Canada, the pressure to 'speed up' the medical transition continues. Finland, on the other hand, promotes non-invasive psychotherapeutic interventions as a first line of action. No surgery is allowed for minors under the age of 18, and hormone therapy is only started if it is established that "Identification with the opposite sex is of a permanent nature and causes severe dysphoria.". When deciding on treatment measures, it must be ensured that gender identity dysphoria has been persistent for at least 2 years and that the person can consistently describe how the dysphoria is detrimental to him or her in everyday situations, in his or her social life or professional career, causing significant suffering. Treatment measures that modify the body to be more congruent with the person's gender identity may be carried out if the person can reasonably justify the need for it and is aware of the associated risks.

The "Council for Choices in Health Care (COHERE Finland) - which works in collaboration with the Ministry of Social Affairs and Health and is responsible for issuing recommendations on services that should be included in public health - was tasked to set up an expert group to evaluate clinical guidelines regarding medical treatment for people with gender dysphoria and the ability of people to access the publicly funded health care system for such treatment.

COHERE stated that "the health problem is gender dysphoria, gender identity variation as such is not a health problem. The recommendation is focused on the treatment of gender dysphoria and therefore also the severity of dysphoria has been defined and also the prerequisites to be able to diagnose gender dysphoria and to be treated. [...] In Finland we do not have legislation that gives people the right to decide what services they can get from publicly funded health care. There must be a medical basis for both diagnosis and treatment.". 

COHERE presented three reportsThe first clarifies the roles of different health care providers in a situation where a child is uncertain about his/her gender identitythe second report focuses on providing general recommendations for the treatment of adult transgender people and, finally, a third publication recommendations for the treatment of gender dysphoria related to non-binary persons and persons with gender identity other than the opposite sex.

In all reports it is specified that in order to improve the appropriate allocation of healthcare resources and ensure the timeliness of the diagnostic and treatment process, Any assessment of the need for psychiatric and psychosocial care, and any treatment deemed necessary, should be organised before the person is referred to the centralised research clinic, so that the evaluation period can be started.. It is medically justified to send people to the multiprofessional research clinics of HUS (Helsinki University Hospital) and TAYS (Tampere University Hospital) if they meet the following criteria: the person has a significant and prolonged gender conflict that causes identifiable suffering in a harmful way in everyday situations; the person was diagnosed and treated for possible concomitant psychiatric symptoms and their continuation during and after treatment, if necessary; it is confirmed that the person has the psychological conditions and sufficient functional capacity for a demanding assessment.

There are also specific indications developed for the treatment of children: i Surgical treatments are not part of the treatment methods for gender dysphoria in children; initiation and monitoring of hormone treatments should be centralised at the HUS and TAYS gender identity research clinics. On the basis of a thorough examination and on a case-by-case basis, the initiation of hormonal interventions that change sexual characteristics can only be considered before the person is 18 years old if it can be established that their identity as the opposite sex is of a permanent nature and causes severe dysphoria. In addition, it must be confirmed that the young person is able to understand the meaning of the irreversible treatments and the benefits and disadvantages associated with lifelong hormone therapyand that there are no contraindications. If a young person (minor or adult) who suffers from gender-related anxiety has experienced or is experiencing concurrent psychiatric symptoms requiring specialised medical care, an assessment of gender identity may be considered if the need for such an assessment continues after the other psychiatric symptoms have ceased and the adolescent's development proceeds normally.

For those who have not yet entered puberty and have experienced symptoms of persistent anxiety related to gender conflict and/or identification as the opposite sex, they can be referred for a consultation visit to the child gender identity research group at TAYS or HUS. If a child before the onset of puberty is diagnosed as having a persistent experience of identifying as the opposite sex and showing symptoms of gender-related anxiety, which increases in severity at puberty, the child can be referred at the onset of puberty to the Child Gender Identity Research Group at TAYS or HUS for an assessment of the need for treatment to suppress puberty. Based on these assessments, puberty suppression treatment can be initiated case by caseafter careful consideration and appropriate diagnostic tests, if the medical indications for treatment are present and there are no contraindications. Young people who have already gone through puberty can be sent to the child gender identity research clinic at TAYS or HUS for in-depth studies on gender identity whether the variation in gender identity and related dysphoria do not reflect the temporary search for identity typical of the developmental phase of adolescence and do not subside once the young person has had the opportunity to reflect on his/her identity, but rather his/her identity and personality development appear to be stable.

Original article heretranslation by Angela Tacchini

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