by Jan Rivers
More than 30 years ago a Commission of Inquiry was held in New Zealand to investigate, amongst other things, whether women with cervical cancer were aware that they had been part of a research project and whether they were properly informed of the treatment options available to them.* Since then NZ has generally believed that the medical conventions around informed consent were set in stone. But the updated “Guidelines for gender affirming healthcare for gender diverse and transgender children, young people and adults in Aotearoa, New Zealand” 2018 should have us asking whether, once again, we have an alarming health failure with experimental treatment and inadequate information.
The concerns about what is happening are multi-faceted. They include:
- Recent UK findings which show that puberty blockers are a prescribing experiment. And New Zealand’s new transgender medicine guideline is directly comparable to what is happening in the UK – an experiment on confused and vulnerable children
- Serious mental health issues are appearing as a side effect of puberty blockers and there is no long term data about the safety of puberty blocker medication. Rather it appears increasingly riskier as more and more side-effects become apparent.
- There is a massive increase in young people seeking to transition but the causes remain unexamined by transgender medicine specialists.
- Meanwhile recent findings show that social media and social contagion are likely causes of the increase especially for young women,
- The transgender community are setting the treatment approach for children who, if left alone, would mostly mature out of their dysphoria.
- Meanwhile in NZ an “affirmative only” approach leads in only one direction – to a transgender identity.
- The bar to being treated with puberty blockers is very low – it would potentially include even children who are unable to explain what is happening to them. However it results in an almost 100% continuation to further treatment including sex hormones and surgery.
- Prior trauma, serious mental health conditions, autism and homophobia will remain unexamined as likely causes of gender dysphoria because NZ mental health professionals are not called on to address these issues, nor to be part of a transgender diagnosis. This is contrary to the approach proposed by the Endocrine Society.
- Amongst other medical issues inadequate information is provided to children and care-givers about the possible impacts on bone density.
- Gay and lesbian children and young people’s presentation and preferences renders them uniquely vulnerable to a diagnosis of gender dysphoria.
- Research about the relatively poor long-term prospects for people who change medically and surgically as adults has been downplayed and important alternative approaches and research which differs to transgender advocates’ perspective are not considered in the guideline.
- Meanwhile a hostile environment for science has developed Internationally where supporting gender ideology is more important than balancing evidence for and against treatment.
- Advocates for more conservative approaches are attacked as transphobic and transgender and gender dysphoria policy is now led by transgender advocates. As well as in the UK and NZ even the World Professional Association of Transgender Health, (WPATH) on which New Zealand’s guideline is based appears to have been impacted by this advocacy.
An experiment on confused and vulnerable children
The change in approach to transgender medicine is international, and is associated with some people’s changing beliefs including belief about the existence of “gender identity” separate from sex, sex roles or sex stereotypes. Accompanying this is an enormous increase in the number of young people reporting their feelings of gender dysphoria but, more importantly, those feelings being interpreted as a medical problem of being “born in the wrong body” and needing to be supported with “gender change”. In NZ the work of aligning bodies with perceptions in children and young people starts with social transformation to the opposite gender and puberty blockers that are administered from the age of 10, or possibly even younger, to prevent the activation of sex hormones and the development of sexual characteristics.
The UK findings show puberty blockers are a prescribing experiment
In the UK the experimental use of puberty blockers began in 2010 has recently been investigated by Oxford-based New Zealand Sociologist Professor Michael Biggs. He later updated the study with additional information. He recounted in detail the circumstances at the Tavistock Clinic in the UK and showed that patients were not told the treatment was experimental, nor were they informed the drugs used are powerful, off-label drugs intended to treat prostate cancer that have “never been certified as safe and effective for treating gender dysphoria”. He showed that there are more side effects and health risks than those listed on the patient consent form. The research by Professor Biggs on the experiment’s reporting showed that it contained basic statistical errors; the results were not properly analysed and negative findings had been ignored. The issue has led to coverage on the BBC and in The Times, Telegraph and The Morning Star.
The UK experience relates directly to New Zealand
The NZ treatment regime adopts the same overall approach as the UK experiment and has been rolled out over the same period. To date the news from the UK research appears to have had no impact in New Zealand. However the consent information provided in NZ raises similar concerns. Gender dysphoric young people and their parents are not told about the experimental nature of the treatment. The earlier 2012 consent form for puberty blockers asked the patient to “understand that the medical effects and safety of long term use of GnRH blockers are not fully understood and there may be long term risks that are not yet known.”
Yet, while possible changes to final height, lower bone density, possible infertility and other factors are listed as risks the caution has disappeared. Meanwhile the research references to the guideline do not appear to (actually could not) provide the evidence of the long-term studies that explain why the caution is no longer relevant. And indeed anecdotal and experimental data not included in the guidelines show that puberty blockers may have additional serious impacts beyond those already identified such as long-lasting effects on brain function or severe impacts on mental health.
There is a massive increase in young people seeking to transition
Reports from the UK indicate a 25-fold increase in children and young people treated at the Tavistock Clinic over the last decade, of whom 35% present also with autism syndrome conditions, and the balance have a high rate of pre-existing mental health problems, self-harm, trauma, sexual abuse and chaotic and troubled family lives. The NZ guideline advice offers no reasons for this and neither does other NZ research attempt to account for the increase in transgender diagnosis which appears to have a similar trajectory to the UK. In the Wellington Region alone total numbers, including adults, increased from 13 in 2006 to 92 in 2016 and the rapid rise is thought to have continued since.
As in the UK pre-existing poor mental health is an important factor in New Zealand transgender medicine. Information from an Official Information Act request from 2018 asked District Health Boards about the percentage of young people of 18 years old and under in their services with gender dysphoria who also suffered from mental illness. The 2017 data from the Waitemata DHB (which includes the centre for dealing with all gender dysphoric youth in Auckland who wish to transition) showed that 48% who had a primary diagnosis of gender dysphoria also had a comorbid mental illness. Information for the Hutt Valley DHB (the corresponding centre for Wellington) said 60% did.
Information about high levels of desistance when untreated has disappeared from the guideline
Further, the authors of NZ’s updated guidelines have changed their minds about what happens to children with dysphoria as they mature. Radio NZ journalist Susan Strongman wrote that the previous 2012 guidelines advised that “most of these children (about three quarters) will not be trans adults, but many will retain some sexual preference or gender issues.” The statement is “poorly expressed” and the clinicians told her that “our understanding/discussion around this has moved on.” But “understanding/discussion’ is not the same as science or evidence.
The available research shows that up to 90% (depending on the study) of children change their minds about their transgender status as they become adolescents and young adults and there is a devastating critique of the “but our understanding/thinking has moved on” analysis here. In contrast, when diagnosed with gender dysphoria, living in opposite gender role and given puberty blockers 100% of children go on to further gender change treatment.
Serious mental health issues are appearing as a side effect of puberty blockers
Biggs’ findings on this are especially worrying. Following treatment with puberty blockers:
“Natal girls showed a significant increase in behavioural and emotional problems, [and parents found] a significant decrease in the physical well-being of their child.”
“a significant increase was found to the suggestion ‘I deliberately try to hurt or kill myself.”
In sharp contrast the NZ guideline suggests that mental health will likely improve. It attributes many of the mental health issues that transgender people suffer to “minority stress theory”. The theory explains poor mental health can be due to the societal effects of anti-transgender attitudes and not to the drug treatment or to individual histories and circumstances. But minority stress theory is just that – a theory.
Homophobia is behind kids deciding to transition
However the evidence that the cause of mental health problems lie elsewhere than minority stress theory is strong. An article by Lily Maynard quotes Stephanie Davies-Arai (the UK Head of Parents’ advocacy group Transgender Trend – an organisation which advocates a cautious approach of watchful waiting for kids with gender issues) – as saying she sees everyday “how the mental health problems of our most vulnerable young people are often made worse after ‘coming out’ as trans.”
There is research evidence that homophobic name-calling causes children to internalise the messages they received from peers and to incorporate these messages into their personal views of their own gender identity.
Indeed, the very diagnosis for “gender dysphoria” in children includes the statement, “A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender” even though research shows that is likely to pathologise kids who’ll grow up to be lesbian, gay and bisexual youth more than kids who’ll grow up to be heterosexual. This is borne out by studies such as this study of girls with gender identity disorder which shows a disproportionate number of them may grow up to be lesbian or bisexual.
The way this pathologising works in clinical practice has been documented by former staff at the UK Gender Identity Service (GIDS) Tavistock clinic who have broken their silence about the approach they were taking in an article in The Times which outlined that:
- So many potentially gay children were being sent down the pathway to change gender; two of the clinicians said there was a dark joke among staff that “there would be no gay people left”.
- “Young lesbians considered at the bottom of the heap suddenly found they were really popular when they said they were trans.”
- Another female clinician said: “We heard a lot of homophobia which we felt nobody was challenging. A lot of the girls would come in and say, ‘I’m not a lesbian. I fell in love with my best girl friend but then I went online and realised I’m not a lesbian, I’m a boy. Phew.’” Several clinicians suspected that some of the “transgender” adolescents were reacting to homophobia at home. “For some families, it was easier to say, this is a medical problem, ‘here’s my child, please fix them!’ than dealing with a young, gay kid.”
A former clinician at an outpost of the UK GIDS clinic in Leeds outlined in graphic detail how preferences for toys were used as evidence for a transgender diagnosis and described how asking critical questions about this saw staff bullied and called “transphobic”. She thought it unlikely that anyone presenting at the UK clinic would be directed away from a trans identity. It seems highly likely that the same factors are in play in NZ transgender medicine. No-one has yet broken their silence, as they have in the UK, and yet private conversations with health professionals indicate there is much disquiet about the current approach.
But numerous young people, including in NZ, are stepping back from hormones, and surgery such as mastectomies, realising they have been misled. Among the reasons for the initial wish to transition revealed by young women “detransitioners” are the painful experience of misogyny. Some realised they were lesbian and didn’t feel able to face homophobia. Others didn’t want to attract male attention or wanted to be safe from sexual assault or to be physically strong. See here and here and here and here.
Inadequate information is provided about the impacts on bone density
Professor Biggs also found that the reassurances on the effect of puberty blockers on bone density were misleading and New Zealand’s advice and consent information is similar. Diet, exercise and possibly bone densitometry tests are advocated and osteoporosis is mentioned as a risk only for those with existing risk factors. But like the UK advice, the guideline doesn’t really make clear that while absolute levels of bone density do not fall by using puberty blockers, puberty is a time when bone density should be increasing considerably – by about 20%. This is as much as it falls by during the remainder of a lifespan. Children are potentially being put at risk of fractures and joint issues with minimal advice about the potential seriousness of the problem. There seems to be little research on early onset osteoporosis, but it could be only a matter of time before more than circumstantial evidence is found.
An affirmative-only approach leads in only one direction – to a transgender identity
The NZ approach is even more extreme than the Tavistock’s. For medical staff to do other than affirm a gender identity and treat a child on the basis of initial presentation and beliefs could be to risk censure now that the Health Ministry has formally adopted the guideline with the expectation that DHBs and GP practices follow it. The effective impact of an affirmative approach is that any causal analysis is unlikely to be explored with children. The guideline says the gender affirming approach:
“involves assisting children to create an environment where their gender can be affirmed. This might require providing education and support for families and schools to be able to support the gender diverse child to navigate a social transition and helping children to develop the coping skills to address any negative reactions that they might experience for being gender diverse.”
Worryingly, NZ’s extreme approach provides for a very limited role for mental health professionals. The guideline suggests mental health support is mainly needed in relation to support, advocacy advice and preparedness for treatment. Clinical diagnosis is downplayed in favour of affirmation – indeed the word diagnosis is used only twice in the whole guideline – both time in relation to mental health not transgender identity. This is in direct contrast to a recent clinical practice guideline from the Endocrine Society which advocates that mental health professionals are a crucial part of a transgender diagnosis. Parents too are pressured to support their children’s identity and to ‘believe’ in the diagnosis because trans children “need” supportive families to prevent harm and suicide attempts. Moreover, serious untreated mental health issues do not prevent “gender affirming care”. The guideline argues that not to treat medically is not an option, saying:
“Withholding gender affirming treatment is not considered a neutral option, as this may cause or exacerbate any gender dysphoria or mental health problems.”
The transgender community are setting the treatment approach for children
The Tavistock Clinic in the UK had been fighting to retain treatment standards based on clinical judgment in the face of pressure from transgender advocates. In contrast the NZ guideline has been developed “in partnership” with the transgender community in an unusual example of patient-led medicine. As well as the guidelines, an OIA response shows one public servant telling another that the Ministry should change things because “the community is not happy with them”. And then suggesting that progress “would be worth signalling”. So the Ministry of Health is working closely to community expectations. But the community in question is the transgender community of adults – not the part of the client base who are distressed and confused children and young people. The medical model imposes a transgender-affirmative-only worldview and an affirmative-only treatment regime on children who may be confused or traumatised but who are mostly not transgender. Whose interests are being served by this? How can it be the right approach? It isn’t, but it has been encoded in the guidelines as if it is.
The bar to being treated with puberty blockers is very low
The recently revised Ministry website says that “blockers are a safe and fully reversible medicine”. … “to help ease distress and allow time to fully explore gender health options.”
And the best practice advice says that “although some neurodiverse people may have difficulty in articulating their gender identity, this should not create an unnecessary barrier to access any relevant gender affirming services. Some people may express their gender identity non-verbally.”
In other words children, who may have autism, or be mute or unable to explain abuse, trauma or homophobia may be put on puberty blockers even if they cannot properly express what they feel.
Important alternative approaches and research are never considered
The guideline is silent on advice about whether social media or social contagion have a part in transgender referrals. But in 2018 Laura Littman described the rapid increase in the number of adolescent girls presenting as transgender and suggested social contagion among friendship groups and on social media as likely causes. She coined the descriptive term “rapid onset gender dysphoria” to describe this. Heather Brunskell-Evans, Michelle Moore, Kenneth J. Zucker, Bob Withers, and James Caspian, who each have extensive professional backgrounds in the area, also counter the relentless transitioning logic of the NZ guideline. The guideline makes no reference to any of their research though, nor does it ever mention the risk of over-diagnosis – giving treatment to people who later detransition – relying instead on an arguably inadequate version of informed consent that:
“involves several conversations between the person and clinician(s) before they start treatments that have an irreversible component to increase certainty that they are adequately prepared and are making a fully informed decision.”
Research about long-term prospects is ignored
The guideline presents treatment as something that requires urgency. But even the references it cites in support of transition are not entirely convincing. The conclusion of a systematic review of the effects of hormone therapy and quality of life from 2016 only references studies that cover 3-12 months after treatment commences and states:
“Hormone therapy interventions to improve the mental health and quality of life in transgender people with gender dysphoria have not been evaluated in controlled trials. Low quality evidence [my emphasis – JR] suggests that hormone therapy may lead to improvements in psychological functioning.”
None of the three studies in the review addressed the placebo effect, the Hawthorne effect or the stimulant effect of hormones which begs whether there is really a strong case for medical intervention.
A study of transitioning that looks at long-term outcomes shows people who have transitioned have high levels of mental illness, suicide and suicide attempts, surely bringing into question whether treatment was the right approach for them.
Meanwhile, children who move directly from puberty blockers to artificial sex hormones will inevitably become sterile and, for boys’, penises will remain immature – at the size of a child’s into adulthood.
Gender change policy in an international context
The NZ guideline makes reference to and relies on the World Professional Association of Transgender Health, (WPATH), the international medical advocacy body that develops Standards of Care. But WPATH has been forced by transactivists to fully adopt uncritical ideological perspectives. Even staff within the organization have been complicit in trying to suppress research on Rapid Onset Gender Dysphoria (ROGD) and desistance. The organisation’s reading list ignores the same alternative voices as the NZ guideline does, despite arguing that it is evidence-based. A former contributor to WPATH standards – Dr Kenneth Zucker, a Canadian (cited above) – was attacked by transactivists at a WPATH conference and cowed medics apologised for inviting him. He was fired from the clinic he had developed for recommending conservative treatment approaches – a decision which was overturned late last year when he received a half-million dollar payout for how he was treated.
A hostile environment for science
There is no doubt that transgender treatment approaches are a contested area of medicine. To do research that contra-indicates the current pro-trans orthodoxy on gender identity is to risk your livelihood.
James Caspian, a counsellor with a specialism in transgender cases, is taking Bath University to the Supreme Court because his proposed research into detransitioners was turned down. Among the reasons given was because it would cause offence and result in criticism of the University. After an initial proposal was endorsed to study people who had detransitioned surgically, he discovered that potential participants were simply too traumatised to take part. He redesigned the study when he was contacted by female to male detransitioners (born women) who were not intending to have further surgery. But he was prevented from restarting the research. Since news of the proposed research’s cancellation became public more than 50 people who had detransitioned have contacted him.
US researcher Lisa Littman’s research was withdrawn in the face of attacks. It faced an academic review and, when re-issued, the case it made was even stronger. However, she had already lost part of her academic contract. Brunskell-Evans was sacked from the Women’s Equality Party and in Moore’s case there has been a campaign to remove her as the editor of a prestigious journal.
Transgender Trend’s Stephanie Davis-Arai was short-listed for the John Maddox Prize, an award which “recognises the work of individuals who promote sound science and evidence on a matter of public interest, facing difficulty or hostility in doing so.”
Prospects for change
The current treatment regime is harmful to children and young people who are signing up to medicalisation in record numbers. The prioritisation of “feelings” over science has been building for decades as treatment models that helped children and young people accommodate to their bodies is lost in favour of medicalisation and a lifetime of drugs and potentially multiple surgical interventions. A NZ rollback on the policy looks unlikely at the moment. But the puberty blocker story has just broken in Australia and a national enquiry will now look into “the safety and ethics of medical treatment for the rising number of trans-gender identifying children and adolescents”. There are estimated to be upwards of 4000 detransistioners on the social media website reddit. How long will it be before some of them seek to take their doctors through a medical negligence process? If and when that happens we may start to see a reversal of the current enthusiasm for treating young children with life-changing medication.
Thousands of adults know all about how childhood gender confusion does not lead to becoming transgender
One initiative might be to ensure young would-be transitioners meet people who have a realistic and intimate understanding of their situation.
Many women, and many lesbians, myself included, have very clear memories of wishing/even believing they were really boys. In my case, born in the 1950s, I wanted to be like Corky, the Circus Boy – a cute orphan of trapeze artist parents who swung the bars one too many times. He had a smart peaked cap and he looked after the elephants. My belief faded but it had been pretty insistent and persistent – one of the tests for gender dysphoria. Later on, the unwanted attention following puberty and emerging sexuality brought more confusion and worry. Would I have been picked up as a trans-kid? It’s quite possible. Is this a stock standard experience of childhood for many women and many in the lesbian community? Yes absolutely. So I know “gender dysphoria” at first hand. Am I glad I wasn’t persuaded at 4, or 7 or 11 that these “symptoms” meant that to “be my true self” I had to be a boy and put on a route to puberty blockers, testosterone, mastectomy, a lifetime of unease and possibly more? Yes. Deeply, deeply glad.
*The Unfortunate Experiment by Sandra Coney and Philida Bunkle, published in Metro magazine 1987, exposed how for decades many women with cervical abnormalities were not treated with the standard of care but were uninformed they were part of an experiment. Gynaecologist Dr Herbert Green, a dominant figure in a hierarchical hospital system, believed that cervical intraepithelial neoplasia (CIN) 3 did not progress to cervical cancer. In his experiment he withheld normal treatment of cone biopsy or hysterectomy from a group of women who had CIN3.