“Don’t Forget Your Homework”
Experts from Finland seek to export their approach to treating trans youth to the rest of the world. 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 Evan Urquhart and Esa Kalliomäki
illustration by Piper Bly
Many thanks to Alyssa Steinsiek, Cassandra Urquhart, Geoff Vitiello, and Laura Braza for providing feedback on early drafts of this piece.
“Would you be angry if I was a boy?”
In the car one week on a trip to the grocery store with his grandmother, 13-year-old Mikael began crying. When his grandmother asked him what was wrong, a secret he’d been keeping for two years finally tumbled out.
“Would you be angry if I was a boy?” he asked.
Mikael’s grandmother, who had raised him since he was five, was not angry. She calmed his fears and made it clear that she and his grandfather would give him their full support, boy or girl. The family sought a referral from Mikael’s school counselor to the nearest of two youth gender clinics in Finland.
The counselor began by seeing Mikael for regular counseling once or twice a week for several months, and then referred him to the transpoli, or gender clinic, in 2019. The family’s first contact with the clinic, in April 2021, was very brief. They said 13-year-old Mikael was not ready, and to call them back after a year. So the family waited and called back the next April.*
Mikael’s first real visit to the clinic was in August of 2022, over three years after having come out to his grandmother as trans. Once there, Mikael was taken away by a nurse to answer questions while his grandmother spoke with a psychiatric professional. It would be the first of many such questioning sessions, first with a nurse and then with a psychologist (or possibly a psychiatrist, he says he isn’t sure of the exact credential), over the course of the next two years.*
The questions the provider asked were strange, and intrusive, and Mikael didn’t like them much. Early on, the nurse asked about his growing chest, a topic he found so painful and embarrassing he told her he didn’t want to talk about. “You’re so immature,” he remembers she said.
According to the Mayo Clinic, gender dysphoria is “the feeling of discomfort or distress that might occur in people whose gender identity differs from their sex assigned at birth or sex-related physical characteristics.” In order to be diagnosed, a patient has to exhibit significant distress. The intense embarrassment and shame Mikael felt as his inner sense of himself as a boy conflicted with the way his body was developing is common for trans boys, as it might be for any boy who suddenly found he was growing breasts. But at the gender clinic in Finland, Mikael says, there was no kindness, no recognition of the stress the intensely personal questioning might cause in a young teen.
“It was hard to answer the questions,” he recalls.
One line of questioning was particularly hard, harder even than questions about his chest. The nurse wanted to know if he touched his genitals, and how he touched them, if he did.
“I told the nurse I did not touch myself, so she said I should. She said I should touch myself, come back and tell her how I did it,” Mikael said. “That was my homework.”
“Don’t forget your homework,” he remembers her saying as the appointment came to an end.
He knew what homework she meant, and felt ashamed, uncomfortable, and annoyed.
Why Finland?
In 2011, Finland tasked the chief of adolescent psychiatry for Tampere University Hospital with establishing the country’s first program providing medical treatment for transgender youth. In doing so, they placed at the head of the program a committed skeptic, a doctor who had vehemently argued against Finland providing any access to gender transition to minors. This choice ensured that gender transition would remain difficult, and most often impossible, for trans people in Finland under 18.
Recently the same woman, Dr. Riittakerttu Kaltiala, has emerged as a leading figure in opposing gender-affirming care, one of the only opponents with direct experience treating transgender youth. In an essay for the Free Press, she laid out her thesis, “The young people we were treating were not thriving. Instead, their lives were deteriorating.” She describes embarking on a course of research to show this was the case for her patients in Finland.
Kalltiala has testified in favor of banning care in Florida, and served as a member of the advisory board for the Cass Review. The Review led to a ban on puberty blocking medication in the UK as well as increased restrictions on hormone therapy for trans youth under 18.
Kaltiala claims her research supports her view about the inefficacy of transition. However, research from other countries shows clear benefits of transition for both young people and adults.
Kaltiala’s claim that young trans people in Finland do not benefit from transition challenges the understanding of major medical organizations in the US, Canada, and beyond, all of whom have recently reaffirmed their belief that treating young people for gender dysphoria early is essential to ensure their thriving later in life.
This leads to an obvious question: If we take Kaltiala at her word (leaving aside that some experts have disputed her interpretation of her results), then results for trans youth patients in Finland are poor while other countries’ results are good. But, if that’s true, does that mean transition is ineffective worldwide, or that Finland, specifically, is doing a poor job? For it to be the latter, Finland would have to differ significantly in the approach taken to treating gender dysphoria than elsewhere.
That is exactly what our reporting shows. Finland does not use the gender-affirming approach that has been adopted by the US, and is extremely conservative even when compared to countries using the more gatekeeping-oriented Dutch protocol. Kaltiala’s Free Press essay, which touts Finland’s record of turning away initially 50 percent and now 80 percent of patients without treatment, supports the interpretation that Finland’s services for trans youth are far outside of the mainstream of such care.
While medical care for gender diverse youth is often treated as a monolith, in truth there are competing approaches that may yield better or worse results. Kaltiala claims Finland’s results are poor, but also that other countries should adopt Finland’s approach. Drawing on a dozen interviews with trans Finns, this story will take a deeper look at how Finland treats trans youth, and at the stress and heartbreak of young patients who found, after years of grueling assessments, mockery, misgendering, and intrusive personal questions, that Finland’s medical services ultimately offered them no help at all.
As for Mikael, he returned to visit the clinic every month or so for several years. The same questions were repeated at every visit, with little change. He was not offered counseling or other support, just repeated questioning about his body, his sexuality, his friendships, and many other things. His story is similar to that of other young trans people Assigned Media spoke with, five in all, who described their experiences as minors at the gender clinics at Tampere and Helsinki. Their stories also closely resemble previous reporting on the topic by Kehrääjä, an Finnish online LGBTQ+ magazine.
Is there any clinical justification for asking children with gender dysphoria to describe their masturbatory habits? In a letter to Kehrääjä, Kaltiala, who was at that time still the Chief Physician of Adolescent Psychiatry at TAYS, and Laura Häkkinen, Chief Physician in charge of the HUS Adolescent Psychiatry Department, addressed the issue in general terms.
"A young person's relationship with their own body is an important aspect of adolescent development, and discussing it is a normal part of adolescent psychiatric evaluation and extensive assessment of adolescent health in general,” the chief physicians wrote to Kehrääjä. “Young people also get to know their bodies through masturbation. Discussing masturbation is a normal part of assessing adolescent health. After all, masturbation is a positive and safe way to explore one's sexuality.”
A larger story in the Stranger about gender-affirming care bans in the US touched briefly on the subject of trans youth being asked about masturbation and sexual fantasies. That story quotes an emailed response by Kaltiala that struck a similar tone, saying masturbation is “an important facet of adolescent development,” and that “in assessing adolescents’ health care needs, different facets of adolescent development are elicited.”
However, American experts say there’s no benefit in putting an adolescent through the humiliation of being asked to describe how they masturbate to a strange adult. A. J. Eckert, an Attending Physician at the Center for Transyouth Health and Development at Children’s Hospital, Los Angeles said that answers to such questions have never been correlated to any outcome for trans people, good or bad, and as such the questions can’t be said to predict successful transition, detransition, or regret. As such, there’s no benefit to the patient in asking them.
Besides which, Eckert said, it’s “gross, gross, gross!”
For 15-year-old Mikael, the invasive questioning was not by any means the worst aspect of his experience with transpoli. He described a tortuous, four-year journey to try and get help for his gender dysphoria, a journey that ended with the door to treatment being suddenly slammed shut.
“Everything was disrespectful,” he said. (He later amended this, saying the psychologists he saw at least were kind, though it seemed there was a new one almost every visit.) “A nurse I spoke to said she views trans men in heterosexual relationships as lesbians.”
This kind of misgendering was another common theme that came up across multiple stories, though not all patients reported this.
For Mikael, it was a small piece of a hostile, unpleasant whole. “That nurse, she had a way of crushing my dreams. When I told her I wanted to be an actor she said something like, ‘You’re not going to get in, you shouldn’t even try to get in because you won’t succeed.’”
During the four years of assessment, Mikael received no other therapy or support from the clinic. He and all the other youth clinic patients we spoke to described feeling that the process was designed to break them and encourage them to give up, rather than help them in managing their gender dysphoria during the years the process took.
Then, when he was 18, he made an appointment with a psychiatrist outside the gender clinic to be assessed for ADHD. When that doctor reported he’d found markers for depression, Mikael’s heart sank. He’d heard stories from other Finnish trans people online about patients being rejected if they were in anything but perfect mental health.
Now, he feared, these markers of depression would be all the reason the clinic needed to send him away.
A few weeks later, his worst fears came true. Although the clinic had never diagnosed, treated, or recommended any kind of treatment for depression during the years that he’d been seen, the doctor at the clinic now told him they felt his mind was not clear enough to start transitioning, and brought the process to an end. Sent off with nothing but a recommendation that he start therapy, Mikael was left to fend for himself.
Losing the hope of treatment after a mental health diagnosis was a common theme across every person we spoke with, not just those who sought help as young people but also those who sought to transition in Finland as adults. Trans Finns who had no mental health diagnoses counted themselves lucky, and told us about friends whose transitions had been refused because they struggled with their mental health. Others who suspected they might benefit from treatment for depression or anxiety spoke of delaying seeking help out of the fear that obtaining help for those issues would result in losing their transition chance.
There are several consistent findings when it comes to the trans community and mental health. The first is that trans people are much more likely than cis people to have difficulties with their mental health. An elevated level of all kinds of psychiatric diagnoses from mood disorders to personality disorders to substance abuse, eating disorders, and self-harm has been found consistently in the research across time periods and countries. The leading explanation for this pattern (which is also observed in other letters of the LGBTQ+ acronym, as well as minority racial and ethnic groups) is minority stress, which is shorthand for the cumulative effects of discrimination that build up over a person’s life.
Many studies have found that medical transition can improve trans people’s mental health significantly, although it does not fully eliminate the gap in mental wellness between trans people and cis. Even the systematic review commissioned by the Cass Review (for which Kaltiala served as an advisor), found moderate evidence that cross-sex hormones improve mental health for trans youth.
A study from Finland, however, has been used to challenge the mainstream understanding that medical transition can improve the lives of transgender youth. The study, whose first author is Sami-Matti Ruuska and whose last author is Riittakerttu Kaltiala, found that young people with gender dysphoria were much more likely to die of suicide than cisgender controls. The authors’ takeaway was that the rate of suicide was not elevated for trans patients after controlling for whether patients sought specialist mental health treatment. (This approach has been criticized elsewhere, but such critiques are outside our story’s scope.)
The paper does not discuss whether a referral for specialist mental health treatment makes it less likely that a patient will receive treatment for gender dysphoria in Finland, as seems to have been the case in many of our patient accounts.
As for Mikael, although he failed to access treatment, he still lives as a man, or perhaps more accurately a boy. In March he said he was typically perceived by strangers as male, but closer to a boy of 14 than a young man of his 18 years. In desperation, Mikael began attempting to find testosterone on the black market.
“I’m 18 right now and there’s so much stuff I should do. I feel my life is on pause as long as I don’t have testosterone,” he said. He can’t (and does not want to) go back to living as a girl but isn’t able to be seen as the young adult man he is.
When we reached out to him again in July, Mikael reported that his mood was much improved. He said he had been successful in finding testosterone. He knows it’s dangerous to be on this medication without regular bloodwork, but feels the risk he’s taking is worth it for the results. He also successfully sought a referral to the adult gender clinic and is waiting to be seen.
“They were really hostile, suddenly.”
Mikael’s story shares much with that of Nuutti, another young trans man, who first entered the youth gender clinic at 16. He says that, despite disliking some of the uncomfortable, probing questions, he found his team at the youth gender clinic to be respectful and kind, even though the staff shifted often, meaning he saw an ever-changing set of providers during his four years of appointments. The appointments continued into his young adulthood when he was told at the age of 20, in a meeting with his mother, that the doctor had determined that he wasn’t really trans.
“In the final meeting they were really hostile, suddenly.” Nuutti said. “My father wasn’t there. ‘Is he not supporting you?’ It was really snarky like that, throughout.”
Nuutti felt there had been no hint that he wasn’t on track for a diagnosis and treatment before the meeting, but says when he arrived at his final appointment the mood was cold. Members of his team, the most recent nurse and the psychologist, refused to look him in the eye. The doctor, who he’d met only once before, explained they believed his gender dysphoria had been caused by some unknown trauma, and suggested he enter therapy to discover what it might have been.
Nuutti had had no adverse experiences like that in his young life. He’d been over this with the psychologist, who wrote that he had no history of trauma, so he felt the explanation made no sense.
“I asked, why did they change their opinion? They called me a ‘young kid’ and said that my mother was trying to change me into a boy, that she had made me transgender.”
Nuutti was devastated, and his mother blamed herself. However, he did not give up. They made a formal complaint and sought to transfer to the adult gender clinic, and this request was granted. Nuutti would then undergo another full year of assessment until finally obtaining a diagnosis at 22. Nuutti has accessed testosterone with the help of an outside doctor, but is still waiting for his official prescription to go through.
“There is no evidence that there are comorbid psychiatric diagnoses that would preclude someone from being transgender,” said Jessica Kant, a lecturer in clinical practice at the Boston University School of Social Work. “It has never been empirically demonstrated that an artificial belief can form to make a cis person think they are trans.”
The state of research in transgender medicine is among the most politically charged medical questions of our time. Critics say that the evidence for interventions in young people under 18 is weak, and recommend making young people wait until they are 18 to begin transitioning. But advocates for trans youth say that undergoing puberty comes with irreversible changes that make life more difficult, changes like a lower voice or facial hair for a trans girl and growing breasts for a trans boy. Although most of the changes can all be addressed medically, early intervention greatly reduces the number and complexity of medical interventions a trans person needs as an adult.
Mainstream medical organizations in the US and beyond agree that persistent, consistent gender dysphoria is highly unlikely to go away on its own after the onset of puberty, and that an approach that helps a young person adjust to life in their stated gender is the best approach. Treatments to help this adjustment can include reversible puberty blocking medications for younger teens, and cross sex hormones for those old enough to give informed consent. Surgical options are much, much rarer in youth, although chest masculinization has proved life-transforming for some severely dysphoric patients for whom puberty blockers came too late.
Fringe theories about what might cause transness or how it could be prevented abound. However, even the most conservative members of the field at least agree that if a patient persists in wanting to transition until adulthood, there is no reason to think that their identity will change, and they should therefore be allowed to proceed. In Finland, however, even this very conservative approach of making young people wait until adulthood does not seem to be followed consistently. Assigned heard from multiple patients who remained at the youth clinic after their 18th birthday and, in Mikael and Nuuti’s cases, were then denied treatment even as adults.
As for puberty blockers, they appear to be prescribed exceedingly rarely in Finland, and never during the period when they would have the most effect. This was explained in a 2017 interview with Dr. Elina Holopainen, a Specialist in Obstetrics and Gynaecology for the clinic in Helsinki (HUS) for the Finnish medical journal Suomen Lääkärilehti. Holopainen said that, in Finland, no treatment is offered until a diagnosis has been finalized, and that no such diagnosis is even considered until the age of 14. She said that a few youth had been treated with GnRH analogues (puberty blockers) at HUS, but only in late adolescence. Intriguingly, the interviewer stated in one of her questions that the medications had never been used in the Tampere clinic (TAYS), though the source of her information was not entirely clear.
Puberty blockers were not discussed with any of the patients who spoke with Assigned.
The question of whether, and how many, children have accessed puberty blockers in Finland is highly relevant because of Kaltiala’s support for bans and limitations on the medications worldwide. If Finland has never regularly used the medications, her ability to speak to their use as a clinician would seem to be on shaky ground. However, it’s unclear whether Assigned simply failed to find trans adults who’d accessed blockers or whether the reports of every person we spoke to, who all said blockers were unheard of in their country, were correct.
Research papers from Finland confuse things further. Every paper we’ve reviewed has aggregated patients treated as minors with those treated as adults. They do not include information on the ages patients’ treatments began, whether and how often puberty blockers were used before cross-sex hormones, or anything about the procedures used to determine when and how to offer medical transition to minors seeking transition care.
“Eventually, I learned I had to lie to them.”
In over a dozen interviews with trans Finns of all ages and experience, Assigned did locate three patients, two trans women and one trans man, who made it through the gauntlet and accessed care through the youth gender clinics. Two of these patients accessed cross-sex hormones shortly before their 18th birthday, while the third did so at the age of 20. This patient is a young trans woman we’re referring to as Henna. Henna’s legal gender has not been changed, and she remains reliant on the youth clinic to approve that step. She told us she fears reprisals from the clinic if they become aware that she spoke out.
Henna first entered one of the youth clinics at the age of 16, in 2019. As with Nuutti, Henna was still in the assessment process when she reached 18.
“In retrospect, the youth ward takes twice the time, and you get treated terribly,” Henna said. “I was asked about masturbation in one form or another in all but two visits, and it’s continued to this day. I knew I couldn’t refuse the question, so I tried to keep the answer short so it would meet their needs and share as little information as possible.”
“Everything was interpreted in the worst way,” Henna continued, describing four years of visits to the youth clinic. “If I said I would like to be a little shorter they’d say ‘Oh, so you like midgets?’ Eventually I learned I had to lie to them. I had to think of every word I said. It became hard for me to eat before the visits. They gave me so much anxiety that even just being in the lobby made me anxious.”
This would seem to diverge greatly from the approach preferred in the US. We asked Eckert to describe the practices of the youth clinics where he’s spent his career. What he described was night and day. In American gender clinics, the foundational goal of treatment is to establish a trusting relationship between the patient and their gender treatment team.
“What you’re describing in Finland is so outdated, it’s like going back to the 80s.” Eckert said. “When you approach someone in this pathologizing way with these sorts of arbitrary, outdated questions, it’s a problem because then people aren’t going to be honest with their providers.”
When patients feel they can’t be honest, Eckert explained, they may hide their doubts or fears and pretend to be certain about medical steps they’re not genuinely sure are right for them. Eckert and others in the affirming-care camp believe this dynamic encourages lying and over-certainty, and that this can lead to many problems, including regret later in life.
The alternative approach Eckert described involves taking time to get to know the patient and build trust, with a focus in early assessment sessions on questions about a young person’s mental health aimed at ensuring they have enough support. Therapy, which was not offered to young people struggling with gender in Finland, is the most common first step.
“None of us have outcomes in mind for our patients,” said Eckert. “We want to follow best practices. It’s not a magic bullet for trans people not to go through puberty, it’s all individualized care.”
This affirming approach differs from what’s known as the Dutch protocol. In countries that follow the protocol, the preferred approach is watchful waiting. However in the most severe cases of gender dysphoria doctors may recommend puberty blockers to prevent the irreversible changes of puberty so that a decision can be made about whether to pursue transition when the child is older.
In Finland, however, the two patients we spoke to who accessed treatment before they turned 18 were prescribed hormone therapy at 17. This happened after years of visits where no treatment, including talk therapy, was made available to them at all. It’s an approach that would seem outside the mainstream for both a watchful waiting and a more affirming approach.
Why Finland has taken such an unusual approach is unknown. Although Assigned made multiple attempts over several months to speak with doctors involved in treating trans people in Finland, including doctors who had treated adult trans patients, Kaltiala, Tampere University, and HUS, we did not receive a response.
This left us to write half a story, with the doctors’ side of the picture almost entirely obscured. Although we would have greatly preferred for our reporting to have included the perspective of the gender doctors of Finland, we felt that the accounts of these patients deserved airing, even if the picture they give is still incomplete. We dearly hope our story will spur further reporting that helps bring the doctors’ perspective into better view.
There are many questions left to answer, as a result. Do years of assessments, invasive questioning about sex and masturbation, and an overall lack of trust between providers and patients contribute to worse outcomes of trans patients in Finland, or is there some other explanation for why Finnish researchers see gender transition so differently than the mainstream? But even with only half a picture, one thing is clear: Finland’s approach to treating gender dysphoria in youth is radically different from that in the US and most of the world. And, even Finland’s own researchers do not claim their unique approach leads to better patient results.
CORRECTION: The first version of this story included some errors that confused the timeline for Mikael’s coming out and early visits to the transpoli. It was over three years, not two, between his coming out and his first visit to the clinic, followed by two years of assessment visits. Additionally, the date of Mikael’s first full appointment was in August of 2022 (a December visit mentioned in the earlier version was his second).
Evan Urquhart is the founder of Assigned Media.
Esa Kalliomäki is a Finnish trans man who has lived around Europe and experienced public trans care in three European countries.