Finland: COHERE and the 2020 recommendation

What did Finland's Council for Choices in Health Care conclude in 2020, and how did Finnish practice change?

Finland’s Council for Choices in Health Care, known in Finnish as PALKO and in English as COHERE Finland, operates in connection with the Ministry of Social Affairs and Health. Its role is to recommend which treatments belong within publicly funded healthcare. Its recommendation, Medical treatment methods for dysphoria associated with variations in gender identity in minors , was adopted on 11 June 2020 and published in summary form five days later (COHERE Finland, 2020).

Background

Finland’s Council for Choices in Health Care, known in Finnish as PALKO and in English as COHERE Finland, operates in connection with the Ministry of Social Affairs and Health. Its role is to recommend which treatments belong within publicly funded healthcare. Its recommendation, Medical treatment methods for dysphoria associated with variations in gender identity in minors, was adopted on 11 June 2020 and published in summary form five days later (COHERE Finland, 2020).

The document did not create Finnish specialist gender services from nothing. Assessment of gender-identity variation, assessment of medical need and planning of treatment for minors had already been legally centralised in multidisciplinary research clinics at Helsinki University Hospital, HUS, and Tampere University Hospital, TAYS. What the 2020 recommendation did was define a clearer national clinical sequence: local psychosocial and psychiatric provision first; specialist assessment when indicated; and narrowly framed medical interventions under the two national units.

This was a significant policy moment because international clinical practice had increasingly been described through an “affirmative” framework, in which a young person’s declared gender identity could be treated as the principal organising fact of care. Finland’s public-health recommendation instead foregrounded distress, developmental context, mental health, functional capacity and diagnostic uncertainty. It did not deny that some minors experience severe and persistent dysphoria, nor did it prohibit every medical intervention. Its central proposition was one of caution under evidential uncertainty.

What the documents say

First-line care was psychosocial, not endocrine

COHERE’s first instruction was that psychosocial support should be available through schools, student health services and primary healthcare. It added that child or adolescent psychiatric consultation, psychiatric treatment and psychotherapy should be arranged locally according to clinical need (COHERE Finland, 2020). This matters because the recommendation did not treat referral to a national gender clinic as the automatic first response to a young person’s uncertainty or distress.

The recommendation further stated that where a young person had concurrent psychiatric symptoms serious enough to require specialised care, those conditions should be treated in the young person’s own region. COHERE said that no conclusion could be drawn about the stability of gender identity while psychiatric illness with developmentally impairing symptoms was active. This is a clinical sequencing rule: stabilise serious co-occurring difficulties, then consider whether a specialist gender assessment remains necessary.

Puberty suppression and hormones remained possible, but on restricted terms

For children who had not started puberty, COHERE allowed referral for a consultation where there was persistent, severe distress associated with gender conflict or identification with the other sex. It did not present medical intervention as the ordinary outcome of that consultation. For puberty suppression, the document specified a more particular pathway: a child diagnosed before puberty with a persistent experience of identifying with the other sex, whose gender-related distress increased during puberty, could be assessed at HUS or TAYS. Suppression could then be initiated only case by case, after careful consideration, appropriate diagnostic examinations, medical indication and absence of contraindications (COHERE Finland, 2020).

For adolescents who had already undergone puberty, COHERE required extensive specialist studies where the dysphoria did not appear to be a temporary phase of adolescent identity development and where identity and personality development appeared stable. Hormonal interventions which alter sex characteristics before age 18 could be considered only after thorough individual consideration. The council required an assessment that the young person’s identification was permanent and caused severe dysphoria; it also required confirmation that the young person understood irreversible treatment and the benefits and disadvantages of lifelong hormone therapy.

COHERE drew a bright line on surgery: surgical treatments were not part of the treatment methods for gender-related dysphoria in minors. It also required initiation and monitoring of hormonal treatments to remain centralised at HUS and TAYS. Finally, it called for the two specialist clinics to collect extensive information about diagnostic pathways, mental wellbeing, social capacity, quality of life, adverse effects and people who later regretted procedures (COHERE Finland, 2020).

The positions

Supporters of the Finnish approach see it as a proportionate response to limited long-term evidence, the irreversibility of some interventions and the complexity of adolescent development. They argue that a national service should not equate compassion with immediate medicalisation, and that young people deserve proper help for anxiety, depression, neurodevelopmental differences, trauma, family difficulties or other problems whether or not gender distress persists.

Clinical evidence available from Finland contributed to that caution. In a retrospective review of 52 adolescents who started cross-sex hormones, Kaltiala and colleagues reported that young people with pre-existing psychiatric treatment needs or difficulties at school, with peers or in everyday functioning often continued to have those difficulties. The authors concluded that medical gender reassignment alone was not enough to improve functioning and relieve psychiatric comorbidity (Kaltiala et al., 2020). A later Finnish register study of 3,665 people who contacted the centralised services between 1996 and 2019 reported increasing psychiatric-service needs over successive referral cohorts; it found that those who did and did not proceed to medical gender reassignment had equal subsequent risk, relative to controls, of needing specialist psychiatric treatment after adjustment for prior treatment (Ruuska et al., 2024).

Critics, including transgender rights advocates and clinicians who favour gender-affirming models, argue that such restrictions can produce lengthy waits, excessive gatekeeping and barriers to care for distressed adolescents. They caution that psychiatric comorbidity does not necessarily make a person’s gender distress less real, and that observational studies cannot establish whether medical treatment caused, cured or failed to change later mental-health outcomes. The World Professional Association for Transgender Health, for example, supports individualised multidisciplinary assessment and includes pathways for adolescent care in its Standards of Care Version 8 (WPATH, 2022).

These are not trivial disagreements. They concern the threshold of proof required before intervening in a developing body, the meaning of informed consent in adolescence, and whether delay itself may carry harms. Finland’s policy did not resolve those disputes; it made an institutional judgement about how public healthcare should act while they remain unresolved.

Interpretation

Beyond Gender’s reading is that COHERE’s 2020 recommendation was a substantive correction to a medical model that had too readily treated adolescent self-identification as sufficient grounds for an endocrine pathway. The council explicitly located gender-related distress within ordinary child and adolescent health services before specialist medical intervention. It required clinicians to take development, psychiatric illness, capacity and permanence seriously. Those are basic safeguards, not hostility to young people.

The most important fact is also the most commonly blurred one: Finland did not impose a blanket ban on all medical treatment for minors. Puberty suppression and sex-characteristic-altering hormones remained possible in exceptional, assessed cases; surgery did not. Describing the policy as either “affirmative care as usual” or a complete prohibition is inaccurate. Its real significance lies in the threshold: medical treatment became an exception requiring justification, rather than an anticipated endpoint of affirmation.

Finland’s insistence on collecting outcome data, including information about adverse effects and regret, was especially prescient. A healthcare system cannot claim to be evidence-led while declining to measure its own long-term results. The 2020 recommendation therefore deserves attention across Europe not as a slogan in a culture-war dispute, but as an example of a public authority applying precaution where evidence was limited and consequences could be lifelong.

Open questions

COHERE explicitly identified the need for better follow-up data. The unresolved questions include which groups of young people, if any, have a favourable long-term balance of benefits and harms from puberty suppression or cross-sex hormones; how fertility, sexual function, bone health and adult wellbeing should be measured; and how frequently diagnostic conclusions change over time.

There is also a transparency question. Finland’s public documents make the overall pathway clear, but it is harder for outside observers to establish comparable, routinely published national figures on referrals, waiting times, diagnostic outcomes, prescriptions, discontinuation, adverse events and regret. Such data should be reported in a form that protects privacy while allowing public scrutiny.

Finally, Finland’s legal recognition of gender changed separately from medical practice. The Act on Legal Recognition of Gender entered into force on 3 April 2023 and separated legal gender recognition for adults from medical examination, diagnosis and infertility requirements (Finnish Government, 2023). That legal reform should not be confused with the clinical safeguards set out in COHERE’s 2020 recommendation for minors. They are distinct policy questions and should remain so.

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