Finländsk könsklinik: 87 % av tonårssökandena var flickor vid födseln och 75 % hade tidigare psykiatrisk behandling

Två år av könsidentitetsvård för minderåriga: överrepresentation av flickor vid födseln med svåra problem i tonårsutvecklingen

Kohort- & registerstudier Autism, trauma & samsjuklighet Stigande diagnoser & social påverkan

Authors: Riittakerttu Kaltiala-Heino, Maria Sumia, Marja Työläjärvi, Nina Lindberg
Journal: Child and Adolescent Psychiatry and Mental Health
Year: 2015
Source: https://doi.org/10.1186/s13034-015-0042-y

Summary

This early report from Finland's newly opened youth gender service described every young person assessed in Tampere between 2011 and 2013. Nearly nine in ten were born female, most had no gender distress in childhood, and three quarters had already needed specialist mental health care. This was often for depression, anxiety, self-harm or autism, and usually began before gender concerns appeared. The largest group developed gender distress in their teens amid wider confusion about who they were, loneliness and high hopes that transition would fix their problems. The authors said this did not match the typical patient the Dutch treatment approach was based on, and that guidelines should take it into account. The study is small and only describes, but it was one of the first to record the changed patient group, and Finland later revised its national guidance.

Key findings

Alla 47 tonåringar som bedömdes för könstransition vid Tammerfors ungdomstjänst 2011 till 2013 ingick. Deras medelålder vid ankomsten var cirka 16,6 år.
41 av de 47 (87 %) var födda som kvinnor, en andel som författarna sa att de inte kunde förklara.
75 % hade varit i specialiserad barn- och ungdomspsykiatrisk vård av andra skäl än könsrelaterat lidande, och 68 % kom först till psykiatrin av skäl som inte hade med kön att göra.
Behandlade problem omfattade depression (64 %), ångest (55 %), självmordstankar eller självskada (53 %), autism (26 %) och psykotiska symtom som att höra röster (13 %).
64 % (30 av 47) hade inget könsrelaterat lidande eller könsöverskridande beteende i barndomen som de eller deras föräldrar kunde minnas, och 62 % började ifrågasätta sitt kön vid 12 års ålder eller senare.
57 % hade blivit svårt mobbade. I 73 % av dessa fall började mobbningen före några funderingar kring kön, mest av skäl som inte hade med kön att göra.
Den största gruppen (23 av 47) utvecklade könsrelaterat lidande i tonåren tillsammans med bredare förvirring över vem de var, ensamhet och mycket höga förhoppningar om att transition skulle lösa deras problem.
Ensamhet och social isolering var det starkaste tecknet på att tillhöra denna grupp: isolerade tonåringar var cirka 9 gånger så benägna att tillhöra den.

Abstract

BACKGROUND: Increasing numbers of adolescents present in adolescent gender identity services, desiring sex reassignment (SR). The aim of this study is to describe the adolescent applicants for legal and medical sex reassignment during the first two years of adolescent gender identity team in Finland, in terms of sociodemographic, psychiatric and gender identity related factors and adolescent development. METHODS: Structured quantitative retrospective chart review and qualitative analysis of case files of all adolescent SR applicants who entered the assessment by the end of 2013. RESULTS: The number of referrals exceeded expectations in light of epidemiological knowledge. Natal girls were markedly overrepresented among applicants. Severe psychopathology preceding onset of gender dysphoria was common. Autism spectrum problems were very common. CONCLUSION: The findings do not fit the commonly accepted image of a gender dysphoric minor. Treatment guidelines need to consider gender dysphoria in minors in the context of severe psychopathology and developmental difficulties.

Conclusion

Adolescents seeking sex reassignment represent a variety of developmental pathways differentiated by the timing of onset of gender dysphoria, psychopathology and developmental difficulties. It is important to be aware of the different groups, or developmental pathways, in gender dysphoric adolescents in order to be able to find appropriate treatment options. In the presence of severe psychopathology and developmental difficulties, medical SR treatments may not be currently advisable. Treatment guidelines need to be reviewed extended to appreciate the complex situations.

Methodological limitations

Small group: Only 47 teens (6 born male), which limits comparisons and makes figures less precise. The authors admit the data are too few for complex analyses.
One clinic: Data come from one of Finland's two youth gender services. The claim that the Helsinki service saw similar patients rests on an unpublished personal communication.
Looking back at clinic files: Records were written to care for patients, not for research, and some information was missing.
Earlier diagnoses unclear: Past mental health problems were taken from referral letters and files that often lacked a formal diagnosis. Only problems that led to treatment were counted, so the rates are probably too low.
Childhood relied on memory: Whether a teen had gender distress as a child depended on what they and their parents remembered during assessment, which may be incomplete.
Groupings made by the authors: The five pathways the authors describe were drawn up by the clinic team from case files, with no reported independent check of how cases were sorted.
No comparison group: There was no group of other teen mental health patients to compare with, so it is hard to judge how unusual these profiles are.
Describes, doesn't explain: The study is a single snapshot. It cannot show whether mental health problems cause gender distress or the reverse, and it reports no treatment results.
May not apply elsewhere: It is a Finnish public service with its own laws (legal and surgical transition only from 18). The authors note the findings cannot be applied to all gender-questioning young people.

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Summary

Key findings

Abstract

Conclusion