Key Findings

• Far higher psychiatric morbidity: Gender-referred adolescents were about three times more likely to have received specialist psychiatric treatment before referral compared to matched controls, and this gap widened after referral.
• Post-2010 surge linked to greater needs: Youth referred after 2010 showed roughly double the pre-referral psychiatric morbidity of the earlier cohort, suggesting increasingly complex cases.
• Psychiatric needs increased after medical transition: Among those who underwent medical gender reassignment, the proportion needing specialist psychiatric care rose sharply during follow-up—especially among those receiving feminising treatment (from ~10% to ~61%).
• Risk remains elevated even after accounting for prior mental health: After adjusting for pre-existing psychiatric treatment, all gender-referred groups still had a 3- to 5-fold higher risk of severe psychiatric morbidity than controls, regardless of whether they underwent medical transition.
• Clinical takeaway: The findings emphasize the need for thorough psychiatric evaluation and continuous mental health support before, during, and after any medical gender reassignment, as psychiatric needs often persist or worsen rather than resolve.

Abstract

Aim: To examine the prevalence of severe psychiatric morbidity among gender-referred adolescents, focusing on gender differences and outcomes related to medical gender reassignment. Methods: Finnish nationwide cohort of all under-23-year-old gender-referred individuals between 1996 and 2019 (n = 2 083) and 16 643 matched controls. Cross-tabulations with X² statistics and Cox regression were used to analyse the data. Results: Gender-referred adolescents showed significantly higher psychiatric morbidity than controls both before (45.7% vs. 15.0%) and ≥ 2 years after referral (61.7% vs. 14.6%). Those referred after 2010 had greater psychiatric needs than earlier cohorts, both before (47.9% vs. 15.3%) and ≥ 2 years after (61.3% vs. 14.2%) referral. Among adolescents who underwent medical gender reassignment, psychiatric morbidity increased markedly during follow-up—rising from 9.8% to 60.7% in feminising gender reassignment and from 21.6% to 54.5% in masculinising gender reassignment. After adjusting for prior psychiatric treatment, all gender-referred adolescents had similarly elevated risks of psychiatric morbidity, with hazard ratios approximately three times higher than female controls and five times higher than male controls. Conclusion: Severe psychiatric morbidity is common among gender-referred adolescents and appears to be more prevalent in those referred after the recent surge in referrals. Psychiatric needs do not subside after medical gender reassignment.

Summary

A Finnish nationwide register study tracked 2,083 adolescents and young adults (under age 23) who were referred to specialized gender identity services between 1996 and 2019, alongside 16,643 matched population controls. The researchers examined severe psychiatric morbidity before and after referral, comparing those who underwent medical gender reassignment (GR) with those who did not. Overall, gender-referred youth had far higher rates of specialist-level psychiatric treatment than controls both before referral (45.7% vs. 15.0%) and two or more years after (61.7% vs. 14.6%). Psychiatric needs were especially elevated among individuals referred after 2010, and among those who underwent medical GR, psychiatric morbidity rose substantially during follow-up. After adjusting for pre-existing psychiatric conditions, all gender-referred groups—regardless of gender or whether they received medical GR—showed a 3- to 5-fold increased risk of subsequent severe psychiatric morbidity compared to controls. The authors conclude that severe psychiatric disorders are common among gender-referred adolescents, do not resolve after medical transition, and may in some cases intensify, underscoring the need for comprehensive mental health assessment and ongoing care.

Conclusion

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.