Home › Research › COHERE Finland

COHERE Finland guideline (2020): psychosocial support first, medical treatment case by case

In June 2020 Finland adopted a recommendation on the medical treatment of minors with gender dysphoria: psychosocial support and, where necessary, psychotherapy come first, and medical treatment is considered case by case and centralised (source). Four years later the Cass Review named the Finnish guideline one of only two international guidelines that could be recommended for use in practice (source).

What is COHERE?

The Council for Choices in Health Care (COHERE Finland) works in conjunction with the Finnish Ministry of Social Affairs and Health and issues recommendations on services that should be included in the range of public health services. COHERE adopted the recommendation on the medical treatment of gender dysphoria in minors on 11 June 2020 (source). It states, among other things, that in light of the available evidence, gender reassignment of minors is an experimental practice (unofficial English translation).

Key recommendations

• Psychosocial support (in school and primary healthcare) and, where necessary, psychotherapy are the first-line treatment.
• Puberty suppression may be considered case by case if gender dysphoria already existed before puberty and increased during puberty; surgical treatments are not part of the treatment of minors.
• Comorbid conditions are treated first.
• Hormonal treatment before the age of 18 is only considered if it is established that the identity is permanent and causes severe dysphoria.
• Hormones only after extensive multidisciplinary evaluation.

The work of Kaltiala-Heino — honest clinical data

Riittakerttu Kaltiala-Heino and colleagues described in 2015 the first two years of the gender identity team for adolescents in Tampere: 41 of the 47 young people referred were born female, 26 percent had an autism spectrum diagnosis, and 75 percent were or had been treated for other psychiatric problems (source). According to the Cass Review, in Finland more than three-quarters of the referred adolescents needed specialist child and adolescent psychiatric support for problems other than gender dysphoria, compared with approximately 33% in the original Dutch group (the Dutch Protocol) (source).

International assessment

The Cass Review (2024) had the international guidelines appraised independently and concluded that only the Finnish (2020) and Swedish (2022) guidelines could be recommended for use in practice, and that the WPATH guidelines "lack developmental rigour" (source). According to the review, the Finnish guideline reached conclusions similar to the Swedish one on the uncertainty of the evidence and urged extreme caution with puberty blockers in young people under 18 (source). There are weaknesses too: on editorial independence the Finnish guideline scored 0 percent (source).

What the Finnish data show

Among the adolescents referred in Tampere, natal girls were heavily represented (41 of 47). Why that is has not been established: the Cass Review mentions greater social acceptance, changed views on gender and sexuality, an expression of broader mental health problems and the influence of peers and media as possible explanations; which one is correct is not established (source). The COHERE recommendation itself does not address ROGD; on that concept see Lisa Littman's ROGD research.