ARTICLE – NORTH & SOUTH
A year ago, I called for a review of the use of puberty blocking hormones for children with gender dysphoria.
CHARLOTTE PAUL – – NORTH & SOUTH
Writing in another publication, I stressed that there were two moral considerations: we should respect people who identify as trans and protect the best interests of children and young people. We needed a frank and fair discussion, to protect both children and adolescents.
The past year has seen a lot of frank and fair discussion — and action — overseas. Regret over gender transition and detransition are widely discussed. More countries are taking action to restrict the use of puberty blocking hormones. But in New Zealand, next to nothing has happened. It is becoming even easier to access these hormones. Standard medical safeguards are being discarded.
New Zealand is becoming more of an outlier in our increasing use of puberty blocking hormones. In 2022, 416 young people aged 12-17 were taking puberty blocking hormones, compared to 48 in 2011, the first year of use for gender dysphoria. We have 11 times the rate of use as England: 110 per 100,000 versus 9 per 100,000. We also have no minimum age for prescribing. If puberty starts at 10 or 11, these children are eligible for blocker
Comparison with Australian gender clinics (which will underrepresent total use but will show trends) shows a levelling off there since 2018, while New Zealand use continues to increase exponentially (see graph, page 32.)
The gist of my concern is the unknown long- term effects of puberty blockers (gonadotrophin releasing hormone agonists) used to treat children with gender dysphoria, the corresponding need for great medical caution and the apparent absence of it in current medical practice in New Zealand. These hormones suppress normal puberty with the aim of relieving suffering and improving final physical outcomes for those wanting to transition away from their birth sex. What started as a sympathetic stance towards a tiny number of children with lifelong gender dysphoria (distress resulting from incongruence between one’s birth sex and experienced gender) has grown beyond recognition. The context is new: the idea that everyone has a “gender identity” (an inner sense of being male or female or non-binary) that overrides biological sex.
Countries that have restricted the use of puberty blocking hormones have used very different means. The European approach has been through the health authorities. The appropriateness and safety of hormonal treatments for children and young people are being evaluated according to the norms of medical practice. For instance, in 2020 NHS England commissioned paediatrician Dr Hilary Cass to conduct an independent review of gender-identity services for youth. This has removed the issue from the political realm. In sharp contrast, in the US, health agencies have been notably reluctant to discuss the possibility of harm, and the issue has become deeply political. In 22 States there are now legal bans on hormones or surgery for anyone under 18.
My hunch is that the involvement of political parties in enacting laws to regulate medical practice is likely to fuel partisan animosity: greater discrimination against trans people on the one hand, and greater uncritical affirmation of hormones and surgery for trans-identified youth on the other. By contrast, if health agencies act according to professional norms and standards to prevent harm to children, there will be less reason for hostility on either side.
The issue is extraordinarily sensitive. I am aware of hostility to people who are trans. I am aware of the difficulty of living as trans. I am aware that public criticism of treatment practices can feel to some people like an expression of that hostility. These things give me pause. Still I feel obliged to write. Wholly understandable sympathy among doctors for children who identify as trans has led to guidelines and practices that are frankly misleading and likely to do more harm than good.
Last year, I wrote at the urging of younger medical colleagues who feared being labelled as transphobic if they spoke out. They were seeing young people in their clinics who had changed their minds about wanting to transition away from their biological sex and were left with their serious mental health problems unaddressed. They doubted there was sufficient psychological assessment before children were prescribed puberty blockers — to help distinguish those few who will remain transgender from those for whom it is a phase or whose distress has another cause. The landscape was changing: a huge and baffling increase in the number of children and young people questioning their gender and being treated with hormones; a change from a preponderance of boys to girls; and from early to late onset dysphoria. Many of those transitioning are on the autism spectrum and many have underlying mental health problems.
Since I wrote, dozens of people have shared with me their disquiet about puberty blockers for children, and also about cross-sex hormones (testosterone for those born as girls and oestrogens for boys) for young people who were transitioning. Puberty blockers can’t be considered in isolation. The great majority of children taking puberty blockers go on to take cross-sex hormones, and similar concerns about consent, appropriateness, and safety are raised when young people are given cross-sex hormones.
A GP wrote: “Like others I am very afraid that in the guise of helping, medicine may risk doing considerable harm”. Another welcomed my “acknowledgment that a lot of clinicians are fearful of speaking up”. A youth worker told me that his experience of working with marginalized teens closely aligned with what I had written. These teens had “complex histories of trauma, and … an unusually high prevalence of trans-gender identification”. In fact, children in state care are disproportionately likely to identify as trans.
Though it is common to attribute mental health problems of trans people to “minority stress”, the evidence for these young people points the other way: the trauma and mental health problems precede transitioning.
The most troubling responses were from parents who felt sidelined by clinicians who had encouraged their children down a medical path — first with puberty blockers and, once their child was 16, with cross-sex hormones.
The Ministry of Health gave some indications they might re-evaluate their position, but those indications were later walked back. In 2021, I asked the Minister of Health whether a review of the use of puberty blocking hormones was planned in the light of steps being taken in other countries. The answer was no: it was “a matter for discussion between a treating physician and their patient”. In 2022, I called for an independent review and for monitoring. The Ministry, presumably in response to the concerns raised by myself and others, announced it was undertaking an “evidence brief” on puberty blockers. It also instigated some small changes. The description of puberty blockers as “safe and fully reversible” was removed from its website.
In March this year, the Ministry explained to Newsroom: “The September 2022 update to the website recognised that overseas jurisdictions, including the UK and Sweden, were reviewing the use of puberty blockers in their health systems, particularly in younger people”; and, “In light of the relatively limited and thin evidence available in this area, the Ministry’s advice was changed to align better with that.”
Yet by May there was still no sign of the promised “evidence brief”, so I wrote to the Director General of Health again, and to the Medical Council and the Health and Disability Commissioner (HDC). What action would they take given their public roles of protecting the health and safety of patients?
The Ministry of Health indicated it might commission an independent review, but in the meantime is extending work on the evidence brief to the end of the year and including mental health issues. Nothing has emerged to date. Nor will a review of the evidence for benefits and harms of puberty suppression be enough; systematic reviews on this topic have already been published overseas. The Cass review has a much wider focus including making recommendations on pathways to care for gender dysphoria, criteria for referral, models of care, clinical management (including the role of puberty blockers and cross-sex hormones), clinical audit and long term follow-up.
The Medical Council responded that it is “able to receive notifications from a range of sources, including the HDC and, where the required standards have been breached, Council can take action to investigate those standards.” Doctors are bound by the Medical Council’s Standards of Good Practice. There appear to be breaches of several standards in relation to prescribing unapproved medicines, assessing the patient’s condition before prescribing, practising in the patient’s best interests, assessing capacity to give consent, and responsibilities to provide accurate and balanced information. Yet so far the Council has declined to investigate. HDC has also declined to investigate a specific complaint alleging lack of informed consent for the prescription of cross-sex hormones to a 16-year-old.
I discovered what is going on in the rest of the world through the mainstream media in other countries. Almost nothing has been published here. Balanced reporting about puberty blockers has appeared in the Washington Post, the Economist, the Australian, and also left wing publications such as the Atlantic, the New York Times and the Guardian….