As recently as 1 May 2025, the US Department of Health and Human Services issued a comprehensive “Review of Evidence and Best Practices” for the treatment of paediatric gender dysphoria.
Of the 23 guidelines studied in the review, only two were recommended for practice by all reviewers, those from Finland and Sweden. The US review says of them: “Both guidelines recommend that psychotherapy – not hormones or surgeries – should be the standard of care for youth with GD (gender dysphoria), and that any use of hormones should be limited to nationally overseen research or exceptional circumstances.
Moreover, the two Scandinavian guidelines were the only ones that based their treatment recommendations on systematic evidence reviews, a key element of trustworthy clinical practice guidelines.”
The Finnish guidelines were issued in 2020 by the country’s Council for Choices in Health Care. The Finnish authorities concluded that the body of evidence supporting puberty blockers and cross-sex hormones for youth is inconclusive.
Importantly, the guidelines explicitly state that “in light of available evidence, gender reassignment of minors is an experimental practice.”
While medical transition remains possible, it is restricted to highly select cases—specifically, adolescents with persistent, childhood-onset gender dysphoria, no major psychiatric comorbidities, and stable identity development through adolescence.
Gender reassignment surgery is not offered to minors in Finland. And special caution is placed on the use of puberty blockers, given emerging evidence about their potential impact on brain maturation and long-term decision-making capacity.
Since the publication of the Finnish guidelines, two major studies have provided additional support for their cautious approach.
One explored psychiatric needs among gender-referred individuals, finding high rates of psychiatric comorbidities and suggesting that the rising number of referrals includes increasingly complex clinical cases.
The second study examined suicide mortality among individuals under 23 and found that there was no statistically significant difference in suicide rates between gender-referred youth and matched controls from the general population.
The Swedish guidelines were issued in 2022 by the National Board of Health and Welfare. They conclude that the risks associated with puberty blockers and gender-affirming treatments likely outweigh the expected benefits for young people.
As in Finland, such interventions are now restricted to research settings, with exceptions permitted under strict clinical oversight. Systematic screening for neurodevelopmental conditions, including autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD), is required early in the evaluation process, with full neuropsychiatric assessments initiated when indicated.
Treatment with puberty blockers is confined to the context of clinical research.
Until such research protocols receive ethics board approval, puberty blockers may be administered only in exceptional cases under the guidelines.
Similarly, the use of cross-sex hormones is permitted only within research studies, with narrowly defined exceptional cases allowed. Only adolescents who meet stringent eligibility criteria for gender-affirming hormone therapy may be considered for surgery, again under exceptional circumstances.
The US document was especially critical of the guidelines issued by the World Professional Association for Transgender Health (WPATH).
It said that those guidelines “have been rated among the lowest in quality and have not been recommended for implementation by systematic reviews of guidelines.
Despite their lack of trustworthiness, for more than a decade WPATH guidelines have served as the foundation of the healthcare infrastructure for gender dysphoric (GD) youth in the United States.”