Seven Countries Changed Their Minds
Finland, Sweden, Norway, Denmark, France, the UK, and the Netherlands all reversed course on youth gender medicine. Why?
Something strange happened between 2020 and 2024, and most people in the United States still have not really processed it.
The countries that invented youth gender medicine, the ones that developed the protocols and exported them, the ones whose evidence base the whole American system was relying on, they looked at their own data and they reversed course. Sweden did it. Finland did it. The UK did it. One after another after another.
And these are not conservative governments. These are not religious movements. These are socialized medicine systems with formal evidence review processes and some of the most progressive social values on the planet. They ran the numbers on what their own clinics had been doing. And they did not like what the numbers showed.
America, meanwhile, was going faster.
Finland got there first
And they were quiet about it. Very Finnish.
In 2020, the Council for Choices in Health Care in Finland, which goes by COHERE or Palko in Finnish, put out a set of updated guidelines for how to handle adolescent gender dysphoria. The language was bureaucratic and it was measured and if you read it carefully it was devastating. The new default was psychotherapy first. Treat the psychiatric comorbidities first. Hormones would be considered only for cases that were severe and persistent and that had been present since childhood and that survived adequate mental health treatment.
What had triggered all of this was a demographic shift in who was actually showing up at the clinics. The Dutch Protocol, which was the foundation that the entire field was built on, had been designed for and tested on a very specific type of patient: children with early-onset persistent gender dysphoria, mostly natal males, kids who had been expressing cross-gender identification since they were four or five years old, and it was unrelenting. But by the late 2010s the patients that were actually walking into Finnish gender clinics were a completely different group. Predominantly adolescent-onset natal females with heavy psychiatric comorbidity, and a lot of them were arriving in clusters from the same friend groups and the same social circles. The old evidence just did not fit the new patients.
Finland did not ban anything. What they did was change the default. Therapy first. And then if the dysphoria still persists after the anxiety and the depression and whatever else have been properly treated, then you talk about hormones for a subset of those patients, and only after extensive evaluation. For one of the most progressive countries in all of Europe this was a significant thing to say out loud. They were saying that the evidence is not sufficient and that they need to slow down.
Sweden was louder about it
Sweden had been one of the earliest adopters of the whole thing. The Karolinska Institutet, which is the institution that awards the Nobel Prize in Medicine, had been prescribing puberty blockers. So when they reversed course in 2021, it carried a very different kind of weight.
What happened was that Karolinska did an internal review of their own patient outcomes. The psychological improvements that they had expected to find were not there. They were just not showing up in the data. The medical risks, though, those were very real and they were accumulating. Bone density was declining in these kids. Nobody knew what the drugs were doing to brain development in the middle of adolescence. And the potential fertility impacts could not be reversed later.
The Swedish National Board of Health and Welfare then commissioned a broader systematic review. And their conclusion, which was published in early 2022, was that the evidence base for hormonal treatment of gender dysphoria in minors was of “very low certainty.” On puberty blockers specifically, what they found was that there was no reliable evidence of psychological benefit. You could not justify the known risks with benefits that nobody had managed to demonstrate.
For those who were under 18, Sweden concluded that the risks appeared to outweigh the potential benefits except in research settings and exceptional cases.
And this is the country that pioneered these treatments. This is the country whose protocols were adopted by other nations around the world. They looked at their own results and they said we need to stop doing this.
The Cass Review
The UK produced what is, as far as I can tell, the most thorough examination of pediatric gender medicine that anyone has ever done. And how it was conducted matters because the methodology is what has made it so hard for critics to wave it away.
Hilary Cass is a veteran pediatrician, a former president of the Royal College of Paediatrics and Child Health, with no prior involvement in gender medicine in either direction. Not an activist in any sense of the word. Just a mainstream clinician with a reputation for being thorough, and NHS England appointed her in 2020 to independently review youth gender identity services.
It took her four years. She brought in the University of York to do systematic reviews of all of the published literature on puberty blockers, on cross-sex hormones, and on psychosocial interventions. The York team went through over a hundred studies. They assessed each one against the basics: was the sample size adequate, were there control groups, was the follow-up long enough, were confounders handled, what were the attrition rates.
And what they found was ugly.
Most of the studies did not meet basic quality standards. In many of them there were no control groups at all, or the controls were inadequate. The sample sizes were small. A lot of the studies had high attrition, which means they lost track of patients and had no idea what happened to those people. The follow-up periods were too short. The proportion of studies that the York team rated as high quality was tiny. And the Tavistock, which was the UK’s main gender service for children, had been treating thousands of young people for years without systematically tracking what happened to them afterward. Thousands of patients and they did not have systematic outcome data. That is not a gap in the research literature. That is a failure at the most basic level of clinical responsibility.
Cass recommended moving away from the affirmation-only model and toward holistic assessment. She addressed the suicide narrative directly and said that the claim that medical transition is the only thing that prevents suicide in these kids, which had been used over and over to pressure doctors into fast-tracking interventions, was not supported by the evidence. And she also made a point that should have been obvious from the start: the patients who were being treated in 2024 were a fundamentally different population from the ones that the protocols were originally developed on. The Dutch Protocol came from carefully selected children with childhood-onset dysphoria, mostly natal males, with low comorbidity and supportive families. The patients who were showing up at UK clinics by the thousands were predominantly adolescent-onset natal females with high rates of autism and depression and anxiety and eating disorders. Using evidence from population A to justify treating population B without ever validating the protocols on population B is a failure of basic medical reasoning, and Cass said so plainly.
She got death threats for it. Activists who had not read the report attacked her personally. That part of the story is, by this point, familiar.
The cascade that followed
After those three, the others moved too.
Norway’s Healthcare Investigation Board launched a formal review in 2023, and they were looking at whether gender-affirming treatment for minors actually met the standards of evidence-based medicine. Their early findings were consistent with what the Scandinavians had already concluded.
Denmark restricted hormonal treatments for minors in 2023. They limited it all to one specialized center and they required extensive evaluation before any medical intervention could happen. Nothing dramatic about it. Just the kind of caution that you would expect when you are giving irreversible drugs to children and your evidence base is this shaky.
France’s National Academy of Medicine put out a statement in 2022 calling for “great medical caution.” They flagged the rapid increase in adolescent girls who were presenting with dysphoria and they called for psychological assessment to come before any medical intervention. France is not known for being medically conservative. They were clearly spooked by what they were seeing.
And then there was the Netherlands. The country that invented the Dutch Protocol. The one whose researchers built the foundational treatment model that every other country in the world had borrowed. Thomas Steensma and others at VU University Medical Centre had started saying publicly that the newer patient cohorts were not showing the same outcomes as the original carefully screened Dutch samples. The protocol was being applied to a population that it was never designed for and never tested on.
When the people who invented something start saying that maybe it is being misused, you have moved past the point where you can credibly dismiss the concern as political backlash or cultural conservatism.
When the people who invented something start saying that maybe it is being misused, you have moved past the point where you can credibly dismiss the concern as political backlash or cultural conservatism.
What WPATH did
While all of this was happening in Europe, the World Professional Association for Transgender Health went in the opposite direction entirely.
Their Standards of Care 8, published in 2022, removed minimum age requirements for hormonal and surgical interventions. Europe was in the process of raising age floors and adding restrictions. WPATH was taking the floors out. You have to read that sequence of events a couple of times to really sit with how strange it is.
And then in 2024, internal WPATH communications leaked. What the files showed was that people inside the organization were aware that the evidence base was weak. They had discussed the lack of long-term outcome data among themselves. They knew that the patient demographics had changed. And they published SOC8 anyway, with fewer safeguards rather than more.
Erica Anderson, who is a transgender woman and who had served as WPATH president, called the organization out publicly. She said that WPATH had abandoned evidence-based medicine and was being driven by advocacy instead of by science. Not some outside critic. Not a politician or a religious conservative. Their own former leader was saying that they had lost their way.
SOC8 was written with significant input from activists and from patients. Patient input is not inherently a problem and I do not think it should be. What came out of that process was a document that reflected a mix of weak clinical evidence along with strong patient preferences along with strong political advocacy. A set of guidelines that pushed toward more access and fewer safeguards at the exact historical moment when every European evidence review was pushing in the other direction.
If you put the Cass Review next to SOC8 the structural problem is obvious. One of them was an independent systematic evidence review that was done by researchers who had no prior stake in the field. The other was a consensus document that was produced by an organization whose members make their living providing the treatments that were being evaluated. The conflict of interest is not hidden. It is built right into the architecture of how the document was made.
Why the American system cannot correct itself
The mechanism here is institutional and it goes a lot deeper than which political team you are on.
The reason that Europe was able to reverse is that systematic review processes actually work in their centralized healthcare systems. Finland’s COHERE issues guidelines and Finnish hospitals follow them. Sweden’s national board reviews the data and practice shifts across the whole country. One body does the review and the system responds. It is relatively clean as these things go.
The American system fragments everything. WPATH guidelines serve as the de facto standard of care. And if you are a doctor who follows those guidelines, then malpractice law protects you. But if you deviate from them, even for good medical reasons, you are legally exposed. So even a doctor who has private doubts about what they are doing has a very strong financial incentive to keep following the protocol. That is a ratchet that only turns one direction. It only tightens.
Professional organizations piled on. The American Academy of Pediatrics, the Endocrine Society, the AMA, they all issued position statements supporting gender-affirming care. And the evidence base that they cited for those statements was WPATH. And the evidence base that WPATH cited was those professional organizations. It is a circular citation loop, and if you do not bother to trace the citations back to where they actually originate, it looks like there is a massive wall of institutional consensus. But if you do trace them back, what you find at the center is very thin.
Several states passed laws that mandated insurance coverage for gender-affirming care in minors. Hospitals that received state funding had to provide it. The legal and financial infrastructure locked the treatment model into place through mechanisms that had nothing at all to do with whether the treatments actually worked or not.
Even if the NIH or the FDA were to conclude tomorrow that the evidence does not support pediatric gender medicine, it is genuinely unclear whether that would change American practice. The legal infrastructure, the insurance mandates, the liability incentives, the professional association statements, all of it operates independently of any single evidence review. There is no central place in the American system where you can pull one lever and change everything. There are fifty levers and about half of them are welded in place.
European institutions faced the same activist pressure that American ones did. Sweden was not immune from pushback. Neither was Finland. The UK saw enormous protests and very aggressive advocacy campaigns against the Cass Review. Their evidence review processes held anyway. Their institutions were still functional enough to change direction when the data demanded it.
Whether American institutions are still functional enough to do the same is a question that is open and that is becoming increasingly uncomfortable to sit with.
The experiment that is running
So now we have a natural experiment, and nobody designed it on purpose.
On one side of the Atlantic you have tightened restrictions, improved assessment, slower medicalization. On the other side you have loosened restrictions, expanded access, and faster medicalization.
In about a decade the data will exist, the detransition rates and the long-term mental health outcomes and the rest of it. And one set of countries will have been right and the other set will look reckless.
The Europeans are betting that they already know which way the data will break. They read the reports from their own clinics. They reviewed the studies that their own doctors had been relying on. The numbers did not support what was being done to these kids. And they had enough institutional integrity left to act on what the evidence actually showed rather than on what they wished it showed.
America’s children are in the other arm of this experiment. Whether that is a defensible position is something that the long-term data will eventually answer on its own. I hope that the people who are confident it will work out are right about that. But the Europeans spent more years doing this than we did and they are not confident at all.
References
Cass, H. (2024). *The Cass Review: Final Report*. NHS England.
COHERE Finland. (2020). *Medical treatment methods for dysphoria related to gender variance in minors*. Council for Choices in Health Care in Finland.
National Academy of Medicine, France. (2022). *Medicine and gender transidentity in children and adolescents*. Statement of the National Academy of Medicine.
Socialstyrelsen (Swedish National Board of Health and Welfare). (2022). *Care of children and adolescents with gender dysphoria: Summary of national guidelines*.
WPATH. (2022). *Standards of Care for the Health of Transgender and Gender Diverse People, Version 8*. International Journal of Transgender Health, 23(S1).