To: Dr Joe Bourne and Steve Barnes

cc: Dame Helen Stokes-Lampard, Health and Disability Commission, Simeon Brown, Matt Doocey, Casey Costello

Tēnā koutou,

I am writing regarding the Ministry’s November 2024 position statement on Use of Puberty Blockers in Gender-Affirming Care, in which the Ministry committed to:

1. “continue to monitor emerging evidence”,

2. “enhance governance and monitoring of gender-affirming care to ensure the safe and evidence-based delivery of gender-affirming care.”, and

3. Noted the establishment of an “external advisory group to consider system wide issues and provide advice relating to gender-affirming care.”

A recently published study, alongside other recent evidence, overseas developments and a material error in the Ministry’s evidence brief bear directly on these commitments. I draw them to the Ministry’s attention because of the Ministry’s overarching responsibility to oversee safe prescribing and to provide accurate information to health consumers and their whanau’s rights regarding treatment options.

The study and other research

Ruuska et al. (2026) have published a nationally representative register study in Acta Paediatrica covering all 2,083 individuals under 23 who contacted Finland’s specialised gender identity services between 1996 and 2019.

Among males receiving estrogen and related treatment, the proportion requiring specialist-level psychiatric care rose from 9.8% before referral to 60.7% in follow-up. Among females receiving testosterone and related treatments, the increase was from 21.6% to 54.5%. In the control population, by contrast, the rate remained essentially unchanged.

The authors state that their findings do “not support the suggested improvement in mental health after medical [intervention] initiated during developmental years, “ and that it “should be noted that in some individuals, medical [intervention] appears to be linked to deterioration in mental health.”

While causality cannot be determined, recent findings from other jurisdictions point in the same direction: McPherson & Freedman (2024) found 15–34% of UK adolescents on puberty blockers deteriorated; Wong et al. (2026) found social support, not medical treatment, predicted mood improvement in Hong Kong; Straub et al. (2024) found a 4.71-fold elevated suicide risk after sex trait modification surgery compared to propensity matched controls in the US; Saxby et al. (2026) found sustained increases in antidepressant prescriptions among Australian cross-sex hormone recipients; while Chen et al. (2023) (which is sometimes used to support the proposition of mental health benefit) reported that two young participants out of a total of 315 committed suicide while being treated with cross-sex hormones.

The nature and purpose of the treatment

The early intervention model involves reinforcing the child’s belief that they are the opposite sex and prescribing hormonal treatments that suppress normal sex hormones and/or introduce supraphysiological levels of cross-sex hormones. Surgeries can also alter hormone production permanently. Sex hormones regulate mood, and GnRH agonists carry adverse effect warnings for mood swings and depression. The possibility that suppressing or disrupting the hormonal milieu of developing adolescents could worsen their mental health is a foreseeable outcome.

Despite this foreseeability the Ministry has recommended off-label hormonal interventions as first-line treatments to minors since 2011 (Ministry of Health, 2011). The recommendation was partially based on the proposition that these interventions would “[alleviate] some of the psychological distress associated with gender variance” (p. 22), although prominent advocates have now apparently abandoned* the mental health improvement proposition in regards to puberty blockers.

With an awareness of these issues, the new NHS gender clinics have not prescribed cross-sex hormones to any minor despite this being lawful (Spencer, 2025; UK Parliament, 2025). The NHS is now consulting on whether to formalise this clinical judgment by banning cross-sex hormones for minors alongside the existing ban on puberty blockers (NHS England, 2026).

These developments, as well as a material error in the evidence brief’s interpretation of Staphorsius et al. (2015) (see Appendix 1), require the Ministry to address the following:

(1) Should the Ministry consider the possibilities that the treatments have no mental health benefit, or make mental health worse for a majority or subset of patients; and raise these possibilities in advice to the Minister?

(2) How likely does the Ministry consider these possibilities to be? What evidence does the Ministry rely on to support the assumption that the treatments improve mental health?

(3) If the Ministry accepts that these possibilities are non-trivial, and noting that it is prior to the consideration of other, not insubstantial, risks, what are the Ministry’s responsibilities regarding the regulation of such interventions?

(4) Health NZ continues to promote the early intervention model. Under the Code of Health and Disability Services Consumers’ Rights 1996, providers are obligated to deliver services of an appropriate standard (Right 4) and to ensure informed consent (Right 6). The obligations under the Code fall on providers, but the Ministry publishes the evidence briefs on which clinicians rely when obtaining informed consent under Right 6. The Ministry therefore contributes to the conditions under which valid informed consent cannot be obtained. The Ministry also has stewardship responsibilities under the Pae Ora (Healthy Futures) Act 2022. At what point does the accumulating evidence outlined above mean that continuing to allow the prescribing of these treatments, without correcting a known error in the evidence brief and communicating new findings to clinicians and families, constitutes a failure of that stewardship? I ask the Ministry to obtain and share legal advice on this question. I note that this letter, and the evidence it contains, is now in the Ministry’s and the HDC’s possession.

OIA requests and erratum

(1) Evidence brief correction. I request the Ministry correct the misinterpretation of Staphorsius et al. (2015) in the evidence brief and issue an erratum or addendum.

(2) Evidence monitoring commitment. The position statement commits the Ministry to “continue to monitor emerging evidence.” I request under the OIA:

1. All communications regarding the Ministry’s formal efforts to monitor emerging evidence.

2. A description of the process the Ministry uses to monitor and assess new publications in this field.

3. All communications regarding the articles mentioned (Appendix 2). In particular, communications where the Ministry has brought these articles to the attention of the external advisory group.

(3) Advisory group. The position statement refers to an “external advisory group” established to “consider system wide issues and provide advice relating to gender-affirming care.” I request under the OIA the terms of reference for this group, its membership, and any minutes or advice produced to date.

(4) Governance and monitoring of clinical practice. I request under the OIA a description of the steps the Ministry has taken to “enhance governance and monitoring of gender-affirming care to ensure the safe and evidence-based delivery of gender-affirming care.”

I appreciate the Ministry’s attention to these matters and look forward to your response.

Nāku noa, nā

Simon Tegg
Director, Genspect New Zealand

*Abandonment or prior claim of mental health benefit – PATHA exec member Dr Rona Carroll, has stated that puberty blockers “don’t necessarily result in a measurable effect at the time they are taken” and that “the main impact is seen when people are older” (Carroll, 2024). Former PATHA President Dr Veale goes as far to say that “[p]uberty blockers are not a mental health treatment” (Veale, 2025). These statements contradict the referenced earlier claim made in the 2011 guidelines (co-authored by PATHA exec member Dr Rachel Johnson) and the statement in the 2018 guidelines (co-authored by Dr. Veale) that “[t]here is good evidence that puberty blocking…significantly improves mental health and wellbeing outcomes” (Oliphant et al., 2018, p. 17)

Appendix 1 - Error in Evidence Brief

The Ministry’s November 2024 evidence brief on puberty blockers briefly addresses cognitive impacts. The Ministry reviewed a single study, Staphorsius et al. (2015), and described the results in these terms:

“The authors found no significant effect of [blockers] on Tower of London performance scores in either [male] or female] adolescents compared to untreated gender-dysphoric controls. They concluded that there were no detrimental effects of [blockers] on executive function” (p. 14).

However, earlier that year in January 2024 the journal Acta Paediatrica had published a review article on the impacts of puberty blockers on neuropsychological function by Professor of Neuropsychology Sallie Baxendale (2024). This article also examined Staphorsius et al. (2015) but described its results differently:

“While the groups did not differ with respect to reaction time on the Tower of London Test, suppressed male to females had significantly lower accuracy scores compared to the control groups. This pattern remained significant after controlling for IQ. Despite this, the reaction time finding has subsequently been reported as evidence for no detrimental effects on performance in citations in the subsequent literature and in policy documents.” (p. 1163)

It seems that the Ministry has misinterpreted Staphorsius et al. (2015) in the way Professor Baxendale describes.

In addition, the Taylor et al. (2024) systematic review, published as part of the Cass Review earlier that year, included a study, Strang et al. (2021), that the Ministry did not. The inclusion or exclusion of individual studies in systematic reviews is not unusual. However, Strang et al. found that longer duration puberty suppression (>1 year) was associated with worse executive function. The Ministry’s evidence brief did not address this finding.

The error regarding Staphorsius et al.(2015) and the absence of Strang et al. (2021) create a misleading picture of the evidence on cognitive effects. Given that the evidence brief informs both the position statement and clinical practice, this should be corrected.

Appendix 2 - Relevant Studies for the Ministry’s monitoring commitment

McPherson, S., & Freedman, D. E. P. (2024). Psychological Outcomes of 12-15-Year-Olds with Gender Dysphoria Receiving Pubertal Suppression in the UK: Assessing Reliable and Clinically Significant Change. Journal of Sex & Marital Therapy, 50(3), 315–325. https://doi.org/10.1080/0092623X.2023.2281986

Ruuska, S.-M., Tuisku, K., Holttinen, T., & Kaltiala, R. (2026). Psychiatric Morbidity Among Adolescents and Young Adults Who Contacted Specialised Gender Identity Services in Finland in 1996–2019: A Register Study. Acta Paediatrica, n/a(n/a). https://doi.org/10.1111/apa.70533

Saxby, K., Buchmueller, T., Carpenter, C. S., Coman, C., & Nolan, B. J. (2026). Mental health treatment among transgender and gender diverse people following gender affirming hormone therapy: Evidence from whole-of-population Australian administrative data. eClinicalMedicine, 92. https://doi.org/10.1016/j.eclinm.2026.103765

Strang, J. F., Chen, D., Nelson, E., Leibowitz, S. F., Nahata, L., Anthony, L. G., Song, A., Grannis, C., Graham, E., Henise, S., Vilain, E., Sadikova, E., Freeman, A., Pugliese, C., Khawaja, A., Maisashvili, T., Mancilla, M., & Kenworthy, L. (2021). Transgender Youth Executive Functioning: Relationships with Anxiety Symptoms, Autism Spectrum Disorder, and Gender-Affirming Medical Treatment Status. Child Psychiatry & Human Development. https://doi.org/10.1007/s10578-021-01195-6

Straub, J. J., Paul, K. K., Bothwell, L. G., Deshazo, S. J., Golovko, G., Miller, M. S., Jehle, D. V., Straub, J. J., Paul, K. K., Bothwell, L. G., Deshazo, S., Golovko, G., Miller, M., & Jehle, D. V. (2024). Risk of Suicide and Self-Harm Following Gender-Affirmation Surgery. Cureus, 16(4). https://doi.org/10.7759/cureus.57472

Wong, C. Y., Ngan, S. T. J., Cheng, P. W. C., Tang, W. K., Chow, L. Y., & Kam, W. K. (2026). Effect of gender-affirming treatments on depression and anxiety symptoms in transgender people: A retrospective cohort study. Frontiers in Psychiatry, 16. https://doi.org/10.3389/fpsyt.2025.1709778

References

Baxendale, S. (2024). The impact of suppressing puberty on neuropsychological function: A review. Acta Paediatrica, 113(6), 1156–1167. https://doi.org/10.1111/apa.17150

Carroll, R. (2024, December 4). NZ is consulting the public on regulations for puberty blockers – this should be a medical decision not a political one. The Conversation. http://theconversation.com/nz-is-consulting-the-public-on-regulations-for-puberty-blockers-this-should-be-a-medical-decision-not-a-political-one-245020

Chen, D., Berona, J., Chan, Y.-M., Ehrensaft, D., Garofalo, R., Hidalgo, M. A., Rosenthal, S. M., Tishelman, A. C., & Olson-Kennedy, J. (2023). Psychosocial Functioning in Transgender Youth after 2 Years of Hormones. New England Journal of Medicine, 388(3), 240–250. https://doi.org/10.1056/NEJMoa2206297

McPherson, S., & Freedman, D. E. P. (2024). Psychological Outcomes of 12-15-Year-Olds with Gender Dysphoria Receiving Pubertal Suppression in the UK: Assessing Reliable and Clinically Significant Change. Journal of Sex & Marital Therapy, 50(3), 315–325. https://doi.org/10.1080/0092623X.2023.2281986

Ministry of Health. (2011). Gender Reassignment Health Services for Trans People within New Zealand (p. 55). https://drive.google.com/file/d/1IMbkUyRQANq9Jp8l1DGm2fuTKVHN5Rc8/view?usp=sharing

NHS England. (2026). NHS England » Clinical policy: Prescribing of masculinising and feminising hormones for children and adolescents who have gender incongruence or dysphoria – public consultation guide. https://www.england.nhs.uk/long-read/clinical-policy-prescribing-of-masculinising-and-feminising-hormones-for-children-and-adolescents-who-have-gender-incongruence-or-dysphoria-public-consultation-guide/

Oliphant, J., Veale, J., Macdonald, J., Carroll, R., Johnson, R., Harte, M., Stephenson, C., Bullock, J., Cole, David, & Manning, Patrick. (2018). Guidelines for gender affirming healthcare for gender diverse and transgender children, young people and adults in Aotearoa, New Zealand. Transgender Health Research Lab, University of Waikato.

Ruuska, S.-M., Tuisku, K., Holttinen, T., & Kaltiala, R. (2026). Psychiatric Morbidity Among Adolescents and Young Adults Who Contacted Specialised Gender Identity Services in Finland in 1996–2019: A Register Study. Acta Paediatrica, n/a(n/a). https://doi.org/10.1111/apa.70533

Saxby, K., Buchmueller, T., Carpenter, C. S., Coman, C., & Nolan, B. J. (2026). Mental health treatment among transgender and gender diverse people following gender affirming hormone therapy: Evidence from whole-of-population Australian administrative data. eClinicalMedicine, 92. https://doi.org/10.1016/j.eclinm.2026.103765

Spencer, B. (2025, April 6). NHS swaps gender drugs for ‘holistic’ care. The Sunday Times. https://archive.ph/EqgSQ

Staphorsius, A. S., Kreukels, B. P. C., Cohen-Kettenis, P. T., Veltman, D. J., Burke, S. M., Schagen, S. E. E., Wouters, F. M., Delemarre-van De Waal, H. A., & Bakker, J. (2015). Puberty suppression and executive functioning: An fMRI-study in adolescents with gender dysphoria. Psychoneuroendocrinology, 56, 190–199. https://doi.org/10.1016/j.psyneuen.2015.03.007

Strang, J. F., Chen, D., Nelson, E., Leibowitz, S. F., Nahata, L., Anthony, L. G., Song, A., Grannis, C., Graham, E., Henise, S., Vilain, E., Sadikova, E., Freeman, A., Pugliese, C., Khawaja, A., Maisashvili, T., Mancilla, M., & Kenworthy, L. (2021). Transgender Youth Executive Functioning: Relationships with Anxiety Symptoms, Autism Spectrum Disorder, and Gender-Affirming Medical Treatment Status. Child Psychiatry & Human Development. https://doi.org/10.1007/s10578-021-01195-6

Straub, J. J., Paul, K. K., Bothwell, L. G., Deshazo, S. J., Golovko, G., Miller, M. S., Jehle, D. V., Straub, J. J., Paul, K. K., Bothwell, L. G., Deshazo, S., Golovko, G., Miller, M., & Jehle, D. V. (2024). Risk of Suicide and Self-Harm Following Gender-Affirmation Surgery. Cureus, 16(4). https://doi.org/10.7759/cureus.57472

Taylor, J., Mitchell, A., Hall, R., Heathcote, C., Langton, T., Fraser, L., & Hewitt, C. E. (2024). Interventions to suppress puberty in adolescents experiencing gender dysphoria or incongruence: A systematic review. Archives of Disease in Childhood, 109(Suppl 2), s33–s47. https://doi.org/10.1136/archdischild-2023-326669

UK Parliament. (2025). Written questions and answers—Written questions, answers and statements—UK Parliament. https://questions-statements.parliament.uk/written-questions/detail/2025-03-18/39059

Veale, J. (2025, November 21). Puberty blockers: Why politicians overriding doctors sets a dangerous precedent. The Conversation. https://doi.org/10.64628/AA.ujspvseta

Wong, C. Y., Ngan, S. T. J., Cheng, P. W. C., Tang, W. K., Chow, L. Y., & Kam, W. K. (2026). Effect of gender-affirming treatments on depression and anxiety symptoms in transgender people: A retrospective cohort study. Frontiers in Psychiatry, 16. https://doi.org/10.3389/fpsyt.2025.1709778

Tēnā koe Minister Brown,

I am writing in support of the pause on puberty blocker prescribing and to highlight the significance of the NHS HORIZON study for New Zealand policy.

In the paper Use of puberty-blocking hormones for gender dysphoria in New Zealand: descriptive analysis and international comparisons [1] my co-authors and I found that New Zealand’s rate of puberty blocker prescribing was several times higher than the Netherlands and England through to 2020. Recent prescribing in New Zealand has fallen after an unexplained peak in 2021 but has remained at a relatively elevated level of more than 100 adolescents starting on puberty blockers each year (see updated chart). The question now is whether a return to these previous prescribing levels could ever be justified.

The government will reassess the pause at completion of the NHS PATHWAYS research programme, which includes a small trial [2] testing puberty blockers alongside psychosocial support on mental health and other measures. However, the more informative component of PATHWAYS is HORIZON [3]. The NHS is currently enrolling approximately 3,600 children and young people into HORIZON—a separate observational study following children and young people referred to gender services who will receive psychosocial support but not puberty blockers.

These are not children with mild concerns. They have been referred through multiple levels of NHS gatekeeping to specialist gender clinics. Many of these HORIZON participants would likely have received puberty blockers under the prescribing practices that existed in New Zealand until recently. The study’s primary outcome measure is mental health and wellbeing.

If these 3,600 young people show stable or improved mental health with psychosocial support alone, it would suggest previous over-prescribing in New Zealand and that our gender-distressed children and young people would likely have done equally well, if not better, without puberty blockers, but with psychosocial support that does not frame normal pubertal development as a medical crisis.

Is it plausible that the thousands of children and young people in the HORIZON study will deteriorate under psychosocial care alone because their pubertal development has not been blocked? The NHS study design reflects a clinical expectation that comprehensive psychosocial care can adequately support the vast majority of young people presenting to gender services. If the results bear this out, it would be very difficult to argue for a return to New Zealand’s previous high rates of prescribing.

Puberty is a time of emotional, cognitive, sexual, reproductive, and physical maturation. When less invasive alternatives exist, subjecting young people to the known risks of blocking normal pubertal development without reliable evidence of benefit is inconsistent with medical ethics. The government should clarify that developmentally informed psychotherapy [4], which explores the full picture of a young person’s distress, is both legal and responsible, as is now the first-line approach in the UK, Finland, and Sweden. The adolescents affected by this pause in puberty blocker prescribing deserve this care.

The Ministry of Health has called for more research into puberty blockers. New Zealand is well placed to contribute and could be world-leading. Our Integrated Data Infrastructure provides retrospective public health data that is among the most comprehensive in the world. A particular concern is bone density with a systematic evidence review indicating that it does not fully recover when the treatment is withdrawn [5]. There have been reports of former puberty suppressed patients with juvenile osteoporosis, chronic back pain, and a high rate of bone fractures in Sweden [6], the UK [7], and the USA [8]. I urge the government to commission an independent follow-up study of the adolescents already treated with puberty blockers in New Zealand. We owe it to them and their families to understand their outcomes.

Nāku noa, nā

Simon Tegg

References

[1] Paul, C., Tegg, S., & Donovan, S. (2024). Use of puberty-blocking hormones for gender dysphoria in New Zealand: Descriptive analysis and international comparisons. New Zealand Medical Journal, 137(1603), 79–88. https://doi.org/10.26635/6965.6587

[2] King’s College London. (n.d.). PATHWAYS TRIAL. King’s College London. Retrieved 29 November 2025, from https://www.kcl.ac.uk/research/pathways-trial

[3] King’s College London. (2025, July 31). PATHWAYS HORIZON. King’s College London. https://www.kcl.ac.uk/research/pathways-horizon

[4] Hutchinson, A. (2025). Cass informed psychotherapy for gender distressed youth. European Journal of Developmental Psychology, 1–19. https:/?doi.org/10.1080/17405629.2025.2540809

[5] Ludvigsson, J. F., Adolfsson, J., Höistad, M., Rydelius, P. -A., Kriström, B., & Landén, M. (2023). A systematic review of hormone treatment for children with gender dysphoria and recommendations for research. Acta Paediatrica, n/a(n/a). https://doi.org/10.1111/apa.16791

[6] Jemsby, C., Mattisson, K., & Lindahl, D. (2021, November 24). Mission Investigate reveals: Several children have been injured in transgender healthcare [Swedish: “Uppdrag granskningavslöjar: Flera barn har fått skador i transvården”]. SVT Nyheter. Updated February 23, 2022. https://www-svt-se.translate.goog/nyheter/granskning/ug/uppdrag-granskning-avslojar-flera-barn-har-fatt-skador-i-transvarden?_x_tr_sl=auto&_x_tr_tl=en&_x_tr_hl=en&_x_tr_pto=wapp

[7] Barnes, H. (2023). Time to Think: The inside story of the Collapse of the Tavistock’s Gender Service for Children. Swift Press.

[8] Twohey, M., & Jewett, C. (2022, November 14). They Paused Puberty, but Is There a Cost? The New York Times. https://archive.vn/LKdgB

Kia ora [Journalist],

I write to you on the topic of transgender health. There are two under-reported stories with direct and important relevance to NZ and your readership. 

1.  A number of European clinical societies have endorsed the NHS’s independent Cass Review or made declarations consistent with its findings. Advice from the Cass Review has led to the NHS ending the routine use of puberty blockers for gender-questioning adolescents.

2. Organisations promoting medical interventions on minors such as the World Professional Association of Transgender Health (WPATH) have come under increasing legal scrutiny. Revelations from unsealed court documents in the USA confirm that WPATH is primarily an activist organisation rather than the scientific organisation it claims to be. 

These stories will be of interest to NZ readers because the local chapter of WPATH is the Professional Association of Transgender Health Aotearoa (PATHA). PATHA has the contract to create the new “national gender affirming care” guidelines and the commissioning document from Health NZ states that the new national guidelines are to be drafted in line with the 2022 WPATH “Standards of Care” version 8 (SOC-8). Some members of PATHA are also members of WPATH – notably former PATHA President and current executive board member Dr Jamie Veale, who is also the current Secretary of WPATH and is listed as an author of SOC-8. 

With policy on medical interventions on minors now diverging dramatically internationally, the basis for current permissive policy settings in New Zealand deserves scrutiny. Slightly over 400 adolescents were being treated with puberty blockers in 2022 –approximately 10x the recent England and Wales per capita treatment rate.

 1. Regarding the clinical society endorsements :

– The UK’s Royal College of Psychiatrists have welcomed the Cass review:
“[the report] offers a roadmap toward more effective, compassionate, and evidence-based care for transgender and gender-questioning children and young people”

– The UK’s Royal College of GP’s issued a statement with advice “[t]o fully implement the provisions of the Cass review in England and adoption of the principles it identifies across the nations of the UK”.

–The Association of Clinical Psychologists UK responded to the Cass review positively: “It has employed the highest clinical and research standards available at this time. We particularly commend the extensive consultation with a range of stakeholders and, most importantly, the young people who use services and their families.”

– The European Society of Child and Adolescent Psychiatry –an umbrella group of 36 national-level child and adolescent psychiatry societies published a statement calling on psychiatrists “not to promote experimental and unnecessarily invasive treatments with unproven psycho-social effects and, therefore, to adhere to the 'primum-nil-nocere' (first, do no harm) principle.” The group pointed to the "poor reliability and instability of a gender dysphoria diagnosis in a specific child over time" and the "possible effects of the decisions to block puberty or preventing medical transitioning on a child's psychosocial development."

– The 2024 German Medical Assembly, a convention with delegates from 17 medical societies, passed a resolution to restrict medical interventions on gender-questioning minors to research settings. Votes were overwhelmingly in favour (120 for, 47 against, and 13 abstentions).   

– The UK Council for Psychotherapy published a statement quoting the Cass Review and reiterating that “[e]xploratory psychotherapy must not be conflated with conversion therapy”; while noting the legal protections to which ‘gender-critical’ therapists are entitled  (i.e. therapists who are sceptical of the proposition that a gender identity is an intrinsic quality of a person). 

These statements are in addition to the national health bodies of Finland, Sweden, Denmark, Scotland, Chile, and authorities in Alberta, Canada and 25 US States restricting or halting puberty blockers for adolescents; authorities in Italy, Norway, the Netherlands, and France initiating reviews; the Editor-in-Chief of the British Medical Journal endorsing the Cass Review; and the World Health Organisation deciding not to pursue guidelines for children and adolescents because “the evidence base for children and adolescents is limited and variable regarding the longer-term outcomes of gender affirming care…”.

Restrictions and bans have occurred or continued under left-wing governments (e.g. Finland, Chile, Denmark and the newly elected UK Labour government).  The issue’s prominence does not appear to be tied to a socially conservative political perspective. In many cases it has been initiated by politically independent health authorities concerned about the lack of evidence supporting medical interventions. 

Prolific prescriber of puberty blockers Dame Sue Bagshaw has framed restrictions of puberty blockers as a “moral panic”. However, the vector of moral panics is not usually weighty independent reviews passing through dozens of expert hands under intense public scrutiny; and Bagshaw may not be aware of the breadth and depth of those who have subsequently supported the Cass Review’s recommendations. When we look at the actual motivations of those advocating restrictions on blockers it is often a concern that same-sex attracted young people have mistaken a tendency to not conform to sex stereotypes for an innate gender identity. This position is now supported by the Cass Review.    

2. Regarding the WPATH revelations

In addition, recent unsealed court [1] documents [2] in the USA, reported in the New York Times, NYT Opinion, The Economist, the Washington Post, the New York Sun and The Hill, confirm that WPATH is primarily an activist organisation rather than the scientific organisation it claims to be. WPATH produces guidelines and research to advance political goals and provide legal cover for the controversial medical practices of WPATH members and has little understanding of evidence-based medicine.

The court documents, obtained through legal discovery, include internal communications between WPATH members and reveal several concerning issues:

1. Lack of consensus and evidence: Guideline authors expressed concerns about the lack of consensus and evidence for SOC-8 recommendations. One WPATH member stated, 

“My understanding is that a global consensus on ‘puberty blockers’ does not exist.” [1]  When WPATH President Dr Marci Bowers was asked under deposition “whether reasonable people could conclude that there is not enough evidence to support the safety or clinical effectiveness of puberty blockers.” Bowers replied “There's not enough high level evidence. Yes, you can – you can – you can say that”. [2]

2. Loosening standards: SOC-8 Authors worried that they had "loosened standards and lost some control." Some clinicians were providing "treatment on demand," and SOC-8 would further "open that up." [1]

3. Influence of social factors: Authors noted that "social factors" and immature decision-making could lead young people to mistakenly believe they are transgender. However, there was "no assessment tool" to differentiate between genuine and mistaken transgender status. [1]

4. Subservient to political and legal objectives: Guideline authors lobbied to tailor the language to influence courts and legislatures, even at the expense of scientific accuracy. One WPATH member admitted, "Our concerns…is [sic] that evidence-based review reveals little or no evidence and puts us in an untenable position in terms of affecting policy or winning lawsuits." [2]

5. Conflicts of interest: The lead guideline author, Dr Coleman, agreed with the statement that “most participants in the SOC-8 process had financial and/or nonfinancial conflicts of interest. Dr. Bowers admitted to making "more than a million dollars" in revenue from sex trait modification surgeries the previous year but found it “absurd” to disclose this while authoring a guideline recommending such surgeries.  SOC-8 readers were misled to believe that "no conflicts of interest among the authors were deemed significant or consequential." [2]. In the USA puberty blockers can cost “tens of thousands of dollars a year” per child. Guidelines that recommend the routine use of puberty blockers could therefore be a lucrative marketing tool for providers. 

6. Suppression of systematic reviews: Guideline authors suppressed the publication of, or avoided commissioning, systematic reviews as reviews that found "little to no evidence"[3] would undermine WPATH’s political objectives. The lead author of the mental health chapter testified that instead of relying on systematic reviews, they "used authors we were familiar with." Another author highlighted concerns about language indicating "insufficient evidence" or "limited data" as it would “empower” groups “trying to claim that gender-affirming interventions are experimental.” [2]

7. Political interference: In the final days before SOC-8 publication, age minimums for adolescent hormonal treatments and surgeries were removed due to external political pressure. WPATH had shared a draft with the Assistant Secretary for Health, Admiral Levine, who identifies as a woman. Levine argued that age minimums would undermine the administration's political goals. The American Academy of Pediatrics (AAP) also threatened to publicly oppose SOC-8 unless age minimums were removed. Despite their low regard for the AAP, WPATH complied, contradicting the wishes of some guideline authors and the WPATH’s own formalised consensus process. WPATH later falsely claimed that the removal was due to a renewed focus on "individualized care." [2]

I have outlined how the Cass Review's recommendations align with a broad section of the international scientific and medical community, potentially including New Zealand. Indeed, high-ranking New Zealand health officials removed the description of puberty blockers as "safe and fully reversible" from the Ministry of Health's website in 2022, diverging from PATHA's stance.

Unfortunately, large sections of the NZ Media have taken an unsustainable narrative, framing critics of medical interventions as fringe voices. Stuff’s 2022/23 position argued that puberty blockers were supported by “accepted science”, and that people who question the scientific basis of puberty blocker benefits are akin to climate change deniers. It is doubtful that a New Zealand audience that reads overseas coverage of the issue will continue to be led by this style of reporting. 

Coinciding with notable decreases in public trust in the media, many journalists now seem to see their role defending ‘accepted science’ and ‘vulnerable communities’. Reporting ‘both sides’ is out and ‘countering harmful misinformation’ is in. This has made often poorly resourced journalists vulnerable to savvy PR. If one side of a debate presents itself as representatives of a vulnerable community and silences critics with accusations of transphobia then quite flaky organisations with their own agendas can gain influence.       

Organisations endorsing the Cass Review typically have exclusively clinical/medical professional membership. In contrast, WPATH and PATHA allow non-clinical members who support their political goals of expanding publicly funded surgeries and hormonal treatments. Notably, PATHA's past and current presidents lack medical qualifications or clinical experience relevant to authoring clinical guidelines. In the photo below the past and current PATHA presidents are respectively Dr Veale: back row far right; and Jennifer Shields: far right.

In 2022 current PATHA president Shields gave the following bio:

“....an artist, advocate, web developer and event producer…interested in alternate spiritualities…a tarot reader and a party witch.” .

PATHA claimed that the Cass Review discarded “101 out of 103 studies” –a misleading statement also spread by UK Labour MP Dawn Butler, who later apologised in the House of Commons. PATHA president Shields called the nearly 4-year and 388 page Cass review final report “trash” the day after its release. Shields also made an unsubstantiated claim that “decades and decades” of evidence shows that a non-medical approach to gender-questioning adolescents leads to “deaths”[3]. Additionally, Shields spread claims that UK restrictions on puberty blockers have lead to a “huge increase” in adolescent suicides alledgedly covered up by the NHS. These claims have been refuted in an independent review by Professor Louis Appleby, a suicide prevention advisor.

Organisations that promote medical interventions do include well-meaning medical professionals, but many will also have conflicts of interest due to their careers built on the medical intervention model. Higlighting this, the AAP faces a lawsuit from a detransitioner alleging civil conspiracy and deceptive practices. In response, medical malpractice insurers are raising premiums or refusing coverage for clinics performing interventions on minors, potentially affecting long-term viability of such practices in the USA.    

New Zealand journalists have noted inconsistencies in the Ministry of Health’s position. This inconsistency may result from competing perspectives within the public service: those with a scientific, evidence-based medicine approach versus those aligned with PATHA. The outcome of this conflict will impact potentially hundreds of children and adolescents who, due to “social factors” (as one WPATH author put it), feel out of place with gender roles and seek medical solutions. The media can perform a public service by covering this issue in a balanced way.      

Best wishes,

Simon Tegg


Endnotes and Citations

[1] Boe v. Marshall - Exhibit 24: Appendix A to Supplemental Expert Report of

James Cantor, Ph.D. https://storage.courtlistener.com/recap/gov.uscourts.almd.77755/gov.uscourts.almd.77755.591.24.pdf

[2] Boe v. Marshall: Defendant’s Motion for Summary Judgement

and Brief in Support https://storage.courtlistener.com/recap/gov.uscourts.almd.77755/gov.uscourts.almd.77755.619.0.pdf

[3] On the 1st of May Shields appeared on the 1 of 200 podcast to discuss the Cass review and made the following statement about the non-medical approach to gender “watchful waiting”:

“And we have, you know, decades and decades of proof that watchful waiting doesn't work, that watchful waiting leads into poor mental health outcomes, and in the deaths of trans people, we've got so much evidence that that doesn't work, thoroughly more evidence than we have of any potential harm that blockers might have.”

I also intend to appeal Professor Blaikie’s decision to the Ombudsman once the Ministry of Health has published their own long-awaited puberty blockers evidence brief, but Dr Bagshaw’s position as a reviewer of this same brief now complicates the situation. 

In 2020 it was reported that Dr Bagshaw had 65 out of 100 gender questioning young people on puberty blockers at the Youth 298 clinic in Christchurch where she was until recently the medical director (rebranded as Te Tahi Youth). This is a remarkably high treatment rate given the size of the Canterbury catchment, and may not represent the total prevalence of puberty blocker prescriptions for gender dysphoria in this region. In comparison, 378 gender questioning children and young people in England and Wales were on puberty blockers in 2022 with a catchment population about 100 times larger. The entire state of Western Australia also had about the same number of children on puberty blockers in 2024 as Dr Bagshaw’s clinic in 2020, despite a catchment population at least 4 times larger. 

Dr Bagshaw’s high prescription rate might be attributed to her commitment to the medical intervention model and an overconfidence in the capacities of adolescents to self-diagnose. When asked to explain the use of puberty blockers Dr Bagshaw was reported to say that blockers are the “standard treatment”  and that “most kids know what they want, most kids know who they are ''. The statements contrast with the view of retired psychiatrist and former President of the British Psychoanalytic Society, Dr David Bell writing in The Guardian and summarising his perspective on the Cass Review:

“The policy of “affirmation” – that is, speedily agreeing with a child that they are of the wrong gender – was an inappropriate clinical stance brought about by influential activist groups and some senior gender identity development service (Gids) staff, resulting in a distortion of the clinical domain”

“Characterising a child as ‘being transgender’ is harmful as it forecloses the situation and also implies that this is a unitary condition for which there is unitary ‘treatment’.”

I hope the Ministry will investigate the substantially higher puberty blocker prescription rates in New Zealand, including those of Dr Bagshaw.

I look forward to the Ministry affirming its commitment to scientific integrity when it publishes similar conclusions on long-term clinical outcomes of puberty suppression as the Swedish, Finnish, NICE, and University of York systematic reviews. However, in the unlikely event that the Ministry’s conclusions were to differ, alongside the involvement of a prolific prescriber with a history of misrepresenting the scientific literature, it might raise questions as to the trustworthiness of the Ministry’s medical information –an outcome which I am sure you want to avoid. 

Best wishes,

Simon Tegg

Sponsor a copy

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Time to Think is meticulously evidenced based on internal documents, legal testimonies and hundreds of hours of interviews with clinicians, patients and parents.

The NHS is now advising the restriction of puberty blockers for gender-questioning young people to medical trials. However in New Zealand puberty blockers are still widely available and used on gender-questioning young people at more than 10 times the rate in England.

The media in New Zealand with some exceptions has been complacent or actively opposed to covering the issue in an in-depth and balanced way. As a result, New Zealand politicians and medical leaders have an imperfect awareness of the scandal.

Please donate and share the campaign site linked below with your networks. We anticipate a number of international and local developments this year and politicians and medical leaders will need to get up to speed. Time to Think and Professor Paul’s article are the best means to achieve this.

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The text below is the lightly edited complaint I submitted to Newsroom in April regarding an inaccurate and highly misleading article on puberty blockers by Marc Daalder. The complaint is 13,000 words and not suitable for the uncommitted reader. It does provide a good overview of puberty blockers and the state of reporting on the issue in New Zealand. It is published here to enhance public discussion about improving media reporting on puberty blockers and the role of scientific evidence in supporting medical claims.

The article did undergo various changes as a result of my complaint but issues remain and the complaint is somewhere in the Media Council’s backlog. I have also included a few details from emails exchanged with Newsroom editors Tim Murphy and Mark Jennings and updates since the complaint was lodged.

[In the original complaint I claimed that Daalder had used the OIA response that I had emailed to Jennings in December as the basis of the article. This was mistaken. Daalder had obtained a similar OIA response from the Ministry of Health website].

I write a formal complaint regarding the Newsroom article “Trans health advice scrubbed after complaints” by Marc Daalder (original headline: “Health advice scrubbed due to anti-trans pressure”)

The article makes three factually incorrect claims. The first two arising from the tagline and first sentence. The article has been revised since publication but the false claims are still present:

“Transgender health advice on the Ministry of Health [MOH] website was "no doubt true" but removed "in the hopes it creates fewer queries", official correspondence reveals

Pressure from the public, including anti-transgender activists, contributed to the Ministry of Health's decision to remove health advice regarding puberty blockers from its website in September.”

(original:  “Pressure from anti-transgender activists led the Ministry of Health to remove health advice regarding puberty blockers from its website”) 

Breaking these statements into claims we have:

1. The decision to remove the “safe and fully reversible” description of puberty blockers was motivated by a high volume of emails from the public and its removal from the MOH website was (partially in the revised version) an attempt to reduce the number of queries. 

2. Some proportion or all of the people who wrote to the MOH and influenced the decision have an antipathy towards trans people (in the original article claimed that all of the people who wrote to the MOH have an antipathy to trans people).

   [The premise of the article is that removed advice must be accurate. If it is not accurate the MOH has simply removed inaccurate or unsubstantiated advice.]

The third is the claim that the Cass review did not make any recommendations on the use of puberty blockers:

3. “In the UK, an interim review of gender affirming care made no recommendations on the use of puberty blockers due to gaps in the evidence base…”

In addition to the false claims there are also several places where by omission or commission the article misleads readers contrary to Media Council principles. These will be dealt with in Section II. 

This complaint is very long and detailed. For the reader’s interest, an article by Bernard Lane covers the main issues more succinctly.

Background

On 10 September I received a tip-off that the MOH advice on puberty blockers was about to change and made an OIA request for MOH correspondence regarding the language update. On 10 October I received a collection of MOH correspondence.

In December I sent the correspondence to Newsroom co-editor Mark Jennnings and several other journalists along with my analysis. A similar OIA response has been published on the MOH website. My version is attached and available in formatted chronological order in this google doc.  We therefore know precisely what information was available to Newsroom and Daalder prior to publication.

The article’s tagline also misinterprets and relies on my tweet to support its narrative. The article describes me as “an activist” but does not name me (originally “anti trans activist” prior to my notifying Newsroom of my intention to take legal action). 

Section I: Factual inaccuracies

Claim 1: MOH Motivation for removing “safe and fully reversible”  

The claim that the MOH was motivated by “pressure from the public” to remove the statement is false because there is no evidence that the officials responsible were even aware that the statement had generated a high volume of emails when the decision was made. 

The MOH flatly contradicts this claim here: “...much of Marc’s story is false, including the headline. The website was not changed due to an anti-trans pressure or any other external pressures. 1/3”

According to the correspondence, Dr Robyn Carey, the MOH’s Chief Medical Officer, made the decision to remove the statement on 22 August 2022. At this time, she and the responsible officials were responding to two emails that alerted officials to the lack of evidence in support of the statement and the statement’s legal issues. All of the ensuing discussion amongst the officials responsible for the revision until the 13th of September concerned a) (unsuccessful!) attempts to identify those responsible for originally drafting and publishing the MOH statement, and b) discussions of the systematic evidence reviews from the national health bodies of Finland, Sweden and the UK and a general concern that “safe and fully reversible” description was not appropriate. There was no discussion of being ‘under pressure’ or setting an objective of reducing queries from the public in the 23 emails amongst these officials sent in the 22 August - 12 September period.

The MOH makes the actual reason clear in their response to the article after publication

"In light of the relatively limited and thin evidence available in this area, the Ministry’s advice was changed to align better with that."

The remainder of this section details the timeline, the officials and their responsibilities, the established practices for evaluating medical claims, and the misleading nature of Daalder’s selective quotation.  

Official’s Responsibilities and Timeline

The advisor quoted in the article: 

• Jenna Osborne-Taylor, Senior advisor, Primary care (now at Te Whatu Ora).
  

The clinical advisors who undertook the rewording and the evidence review strategy: 

• Dr Robyn Carey, Chief Medical Officer (CMO) (former, Dr Joe Osbourne is now in this role)

• Dr Tim Jelleyman, Chief Clinical Advisor, Child and Youth Health (CCA-CYH)

• Dr Sayali Pendharkar, Deputy Chief Science Advisor (DCSA)

In the period 22 August - 12 September: CMO Carey makes the decision to revise the statement and attempts to discover those originally responsible, CCA-CYH Jelleman drafts the revision, and DCSA Pendarkhar recommends an evidence collection and review strategy. A selection of email correspondence is presented below in the Appendix. The full OIA response received from the MOH is attached. However the email chains are out of order. To make comprehension easier I have formatted and arranged the correspondence in chronological order in this google doc.

The article hinges on an email dated 13 September sent by Osborne-Taylor to CCA-CYH Jelleyman three weeks after the decision to revise the webpage had already been made. Osborne-Taylor raises concerns about the large number of queries received by the Royal New Zealand College of GPs (RNZCGP) (and the MOH) relating in particular to the “safe and fully reversible” wording and suggests a revision “in the hopes it creates fewer queries”. Osborne-Taylor also believes the advice to be “no doubt true”. 

According to Osborne-Taylor’s LinkedIn, she has no medical qualifications and was in executive assistant or communications roles until April 2021 when she was promoted to advisor, primary care, then to “senior advisor” six months later. Her main qualification appears to be English and Film, Television and Media studies. At the time of correspondence Osborne-Taylor had a total of 18 months experience in primary care advisory roles. In contrast, the clinical advisors are all medically trained and have decades of experience in relevant specialist areas (e.g. child and youth health, medical evidence).

CCA-CYH Jelleyman responds to Osborne-Taylor 26 minutes later with the initial draft revision, and counters her view noting that concern about the statement is “appropriate”.

Systematic Evidence Reviews, Professional Bodies and Medical claims

If it wasn’t “pressure”, what influenced CMO Carey and the clinical officials to change the wording? The article lists a number of medical professional bodies that support medical intervention on gender-questioning adolescents including the Professional Association of  Transgender Health Aotearoa (PATHA). PATHA is the local chapter of the international group the World Professional Association of Transgender Health (WPATH). Why do Drs Carey, Jelleyman and Pendarkhar appear to weigh the reviews from Sweden, Finland, and England more strongly than the views of organisations like PATHA and WPATH? To the lay reader it may appear that a stronger weighting given to the former indicates a bias. 

For one, both PATHA and WPATH are more correctly described as hybrid activist-professional groups. PATHA and WPATH do not require medical qualifications to qualify for membership. For example, one of the co-authors of the PATHA guidelines is Jennifer Shields, who offers the following bio: “....an artist, advocate, web developer and event producer…Jennifer is also interested in alternate spiritualities…She is a tarot reader and a party witch.” . Another example is Susie Green, one of the co-authors of the children chapter in the recently released WPATH guidelines. Green was until recently the CEO of “Mermaids” children’s charity in the UK. Green has an IT background and no medical qualifications. Green abruptly resigned from Mermaids in November after facing a string of controversies, including playing a role in the downfall of the Gender Identity Development Service (GIDS) clinic in London. To be sure, these groups do include medical professionals –that is, ones directly involved in the use of puberty blockers and with a conflict of interest in the dispassionate examination of the evidence for this intervention. Psychiatrist Dr Steven Levine served as the committee chair for the development of the fifth edition of the WPATH guidelines 1997-1998, before resigning in 2002 “due to [his] regretful conclusion that the organization and its recommendations had become dominated by politics and ideology”. He describes WPATH as :

“...a self- selected subset of the profession along with its many non-professional members; it does not capture the clinical experiences of others. WPATH claims to speak for the medical

profession; however, it does not welcome skepticism and therefore, deviates from the philosophical core of medical science.”

I outlined the controversies surrounding PATHA and WPATH to Newsroom co-editor Mark Jennings in my email to him in December and am surprised that these salient facts did not make it into the article.

However, the main reason for weighting these is the nature of the reviews conducted by the national health bodies and the practice of evidence-based medicine in health policy-making. The reviews from the Swedish, Finnish and English health bodies are systematic evidence reviews not merely literature reviews. Science journalists like Daalder should know the difference between these and be able to explain it to readers. A systematic evidence review means the literature search and evidence quality assessment are standardised and reproducible using techniques like GRADE. Therefore the conclusions of systematic reviews are much more trustworthy than those of literature reviews where authors have followed an ad hoc literature search and are liable to interpret selected evidence to support preconceived conclusions. The second key concept in evidence-based medicine is that the strength of a recommendation in a guideline should be linked to the strength of the evidence supporting the recommendation.

As it happens, one of the creators of the GRADE, Professor Gordon Guyatt and another evidence-based medicine expert Professor Mark Helfand were recently asked to comment on the trustworthiness of the reviews conducted by WPATH and the Endocrine Society and their guidelines in a February article in the British Medical Journal. Guyatt “found “serious problems” with the Endocrine Society guidelines”, because “weak evidence” supporting puberty suppression was paired with a strong recommendation to treat. Helfand noted the WPATH guideline “[lacked] a grading system to indicate the quality of the evidence”, amongst other deficiencies. In other places the evidence summaries in the WPATH guidelines appeared to contradict the summaries in the underlying evidence review. Notably, WPATH did not conduct a systematic review on puberty blockers, yet still made a recommendation to treat. In Professor Guyatt’s view this “violat[es] standards of trustworthy guidelines”.

The above point is crucial to understanding why the decision to remove the” safe and fully reversible” statement was made relatively quickly by CMO Carey. The onus is on those making a claim to present evidence to support it. When no evidence supporting this claim is available, and when recent systematic evidence reviews indicate that the risks of the treatment outweighs benefits, it would be highly irresponsible to leave the statement in place. The real question is how the statement was published on the MOH website in the first place (which is still a mystery). In a 5 September email DCSA Pendarkhar underlines the  former point and recommends that the PATHA guidelines need updating “in light of the [UK] review”.       

Misleading Selective Quotation

Daalder’s selective quotation from Osborne-Taylor’s 13 September email leaves out important context that misleads readers. Importantly, you will note the article’s quotation does mention Dr Bryan Betty ONZOM, the medical director of the Royal New Zealand College of GPs (RNZCGP) [former], but this is never elaborated upon. Dr Betty is also mentioned In an email from Osborne-Taylor to another non-clinical official who is not involved in th revision on 8 September. In the following quotes the section Daalder included is in bold, but the remainder was omitted from the article.  

8 September:  

“I've just been in a meeting with Dr Bryan Betty and others around a joint attack regarding the number of queries the College, (and we) are receiving relating to puberty blockers”

And the 13 September email to CCA-CYH Jelleyman that hinges the article:

“...we have also been made aware that our colleagues at RNZCGP and in primary care settings are receiving a growing number of queries relating to the highlighted section of the guidance specifically:

“Blockers are a safe and fully reversible medicine that may be used from early puberty through to later adolescence to help ease distress and allow time to fully explore gender health options”.

After discussing with Dr Betty et al, I was hoping it might be possible to get this section of the website revised in the hopes it creates fewer queries. I'm sure you're aware there are both members of the public and medical professionals who disagree. We will be working towards putting together a joint statement on the efficacy and safety of puberty blockers to use as a standardised response for such queries.

Please also note that we have been alerted by our colleagues at PATHA that this line being used negatively in the media - see here: https://www.nzherald.co.nz/lifestyle/identity-crisis-have-we-gone-too-far-in-letting-kids-change-their-gender/TT4LEA5FS7JYWFYWWCCBAEB6JM/ …”

The full emails add important context.

First, in the 8 September email and in the omitted part of the 13 September email Osborne-Taylor emphasises that it is the RNZCGP that is receiving the queries (along with the MOH). Presumably queries from GPs. Unlike other jurisdictions where the treatments for gender-questioning young people are handled by specialists, GPs in New Zealand have been asked to take on primary responsibility for treatment. It is not surprising then that many GPs would have concerns about the evidence base for treatment and the accuracy of information on the MOH website. This context is missing from the article which states that it is “anti trans activists” that pressured the MOH.

The MOH confirms this point with a tweeted response on March 28:

“The line from an advisor that we changed the website “in the hopes it creates fewer queries” was lacking some context. The advisor was referring mainly to enquiries to GPs, reflecting the view from GPs that clearer advice on the webpage may assist them with their clinical care”

Osborne-Taylor then takes it upon herself to disagree with medical professionals, and presumes that the MOH will be issuing a “joint statement on the efficacy and safety of puberty blockers”. This never happens as the MOH statements quoted in the article make clear. She also believes that removing “no doubt true” information is warranted –an ethically dubious position but she is the only official in the correspondence to take this view. 

This contradicts Daalder’s tweet advertising the article (my emphasis):

“Internal correspondence now shows officials [plural] knew the advice was true but removed it "in the hopes it creates fewer queries"”

This is false. There was only one non-medical official that believed the advice to be true. Daalder’s tweet leaves the impression that the statement was generally accepted as true within the MOH, contradicting the views of Drs Carey, Jelleyman, and Pendarkhar. Following standard journalistic practice, Daalder must delete this tweet and issue a correction clarifying that one official with no medical qualifications believed “safe and fully reversible” to be true and that it was not shared by others [Daalder has deleted the tweet but has not issued a clarification]. To leave the tweet up spreads misinformation that the MOH actively hides ‘accurate’ health information –an irresponsible position that undermines MOH public health initiatives.         

Second, Osborne-Taylor’s other motivation for rewording seems to be to remove opportunities for criticism of medical intervention on children and young people for the benefit of PATHA: “Please also note that we have been alerted by our colleagues at PATHA that this line being used negatively in the media”. She references an article published in The Listener the week before and syndicated to the NZ Herald by Emeritus Professor Charlotte Paul. Paul’s article also notes that her medical colleagues who have concerns about the widening access, lack of quality evidence for benefits, and potential harms of puberty suppression; and queries the appropriateness of “safe and fully reversible” statement on the MOH website. Newsroom editors and the media council may have wondered why we don’t hear from these medical colleagues directly, but the prospect of defamation by Newsroom as “anti-trans” should now make the reason for their reticence abundantly clear.

Rather than responding directly to Professor Paul’s article and losing a debate perhaps PATHA knew that “safe and fully reversible” cannot be defended with evidence and wanted to strategically retreat [subsequently PATHA Vice President Dr Rachel Johnson has doubled down on the ‘safe and fully reversible’ claims]. 

Third, the possibility that, like Osborne-Taylor, Dr Betty believes puberty suppression of gender-questioning adolescents is a “safe and fully reversible” treatment but also thinks the removal of this information is warranted to ‘create fewer queries’ is left hanging by the article.  In my view it is highly unlikely that a distinguished medical leader would take this ethically dubious position. It would be useful if Newsroom could follow-up and ask Dr Betty his views on this matter.

Claim 2: People who wrote to the MOH have an antipathy towards trans people.

The article presents no evidence that the people who wrote to the MOH about the issue have an antipathy towards trans people. I am the unnamed source for the information that over 50 people have written to the MOH regarding the unsupported “safe and fully reversible” statement over a couple of years. The campaign took place 2 years prior to the update and had no influence on the decision to update the wording. The two emails that did alert clinical officials were a matter of public record prior to the article’s publication and display no transgender antipathy. The emails simply describe the weak evidence base, concern for misdiagnosis and overtreatment on a young LGB population, and legal complications of promoting puberty blockers to the public.   

It is not uncommon for proponents of puberty suppression to accuse a sceptical person or group of being “anti trans”. Some people believe that all young people given the treatment for a full duration are innately transgender for whom the treatment is highly indicated. For proponents, opposition or mere scepticism to a ‘necessary’ treatment makes a person ‘anti-trans’. It goes without saying that it would be highly irresponsible for a publication to take this position when the Media Council has previously ruled the issue to be  “a sensitive, complicated, and important topic, where there appears to be evolving scientific debate.”

For example, the Speak Up For Women group has also welcomed the MOH change in advice. People who wanted to prevent SUFW from booking public venues in Palmerston North accused SUFW of being an anti trans hate group in 2021. SUFW were initially prevented from booking public venues but took the Palmerston North City Council to court. In the high court judgement Nation J found that Speak Up For Women “cannot rationally be described as a ‘hate group’” and no evidence to that effect was presented.

The Email campaign

I am the unnamed source for the information that over 50 people have written to the MOH regarding the unsupported “safe and fully reversible” statement over a couple of years. The article paraphrases my November tweet drawing attention to the change in wording, but does not link to it or name me:

“.@minhealthnz finally removed the "safe and fully reversible" language from the website in September. This was after >50 people emailing them over the years and pointing out that this language was unfounded and misleading”.

The article originally described me as an “anti trans activist”, but after I sought legal advice on defamation proceedings and raised the matter with Newsroom editor Mark Jennings, “anti trans” was dropped from this description. The image caption still has the original phrasing: “After the change was revealed, one anti-trans activist said more than 50 people had emailed the ministry to get it to remove the line.” The revised article still makes four further references to “anti-transgender activists”, “anti-trans activists”, “anti-trans pressure” and the “anti-trans movement” in the article body and the url is still “health-advice-scrubbed-due-to-anti-trans-pressure” [The curent article has removed most references to ‘anti-trans’].

I completely reject this characterisation. I advocate that children and young people who identify as trans or express distress with their sexed body should receive the highest quality advice and healthcare –that is, evidence-based care. All reference to “anti-trans” or such must be removed (including the url). 

The article also mentions another article published by Newsroom in August last year that questioned the MOH wording. The original article implied the author was part of an anti-trans pressure campaign to remove the statement. The revision now attempts to clarify that when the author raises questions on the appropriateness of “safe and fully reversible” it is “distinct from the anti-trans movement”, and features an apology that also appears to be in response to a defamation complaint.

Newsroom undermines the apology by adding that the implication occurred “in the context of discussing anti-trans arguments” [Newsroom have now changed this to “in the context of discussing anti-trans opposition to puberty blockers”]. But no anti trans arguments are made in the article? Newsroom must clarify what they mean here. Or is Newsroom suggesting that questioning the accuracy of advice that the MOH subsequently confirmed as inappropriate is anti trans? Is opposing the use of a drug used to chemically castrate sex offenders anti trans? What about agreeing with the MOH that the evidence in this area is “relatively limited and thin”? Is the MOH anti trans?  It seems that when named people with access to legal counsel ask questions or present arguments they are permitted to be “distinct from the anti-trans movement” , while when nebulous groups of unnamed people (or more obliquely identifiable people) do the same things they remain “anti-trans”. 

When I wrote the tweet I was thinking of 30-40 odd emails that were sent in mid to late 2020. To my knowledge, none of the people that sent these emails are anti-trans and they all received a form response. It's possible some had an antipathy for trans people, but it would be extremely odd for such people to write to the MOH arguing that kids who identify as trans should receive evidence-based health advice, or concerned that the harms of treatment outweigh the benefits.     

In any case, the email campaign was an abject failure. I allude this in the tweet that followed where I speculate that it was the recent articles in Newsroom and The Listener articles that prompted the change:

“Its not entirely clear what prompted the change but could have been the recent articles in Newsroom https://newsroom.co.nz/ideasroom/gender-questioning-kids-being-let-down#Echobox=1660764318 and the Listener (syndicated to the Herald) https://nzherald.co.nz/lifestyle/identity-crisis-have-we-gone-too-far-in-letting-kids-change-their-gender/TT4LEA5FS7JYWFYWWCCBAEB6JM/”

An unknown number of people sent emails before and after this campaign bringing my estimate to “>50”. I believe that “safe and fully reversible” description was first published on the MOH site in January 2017. Emails may have been more frequent after the NHS changed similar advice in early 2020. A volume of 50+ emails over several years hardly constitutes a significant burden for an organisation of MOH’s size, or something that would plausibly provoke clinical officials to remove health advice. It is possible that if the content of such emails reached the right decision-maker then that could trigger a change in position, but that is not what the article claims.      

Daalder’s tweet promoting the article is again in error (emphasis mine):

“NEW: After an anti-trans pressure campaign last year [2022], the Ministry of Health scrubbed transgender health advice from its website.”

The actual email campaign was two years prior to the update and sank without a trace. On what basis does Daalder contradict me, the source of this information?

The Consumer Correspondence

If the 2020 email campaign did not alert the clinical officials to the poor evidence base, what did? After receiving the MOH correspondence in October I followed up and requested the “consumer correspondence” to which the clinical advisors are responding. This OIA response is published in the MOH website. The MOH responded with two emails, both sent on August 12. One is from the LGB Alliance Aotearoa –a group defending the interests of same sex attracted people, and the other is from an unknown person whose name has been redacted. Neither email expresses an antipathy to trans people.

The LGB Alliance email highlighted whistleblower reports from the Gender Identity Development Service (GIDS) clinic in London of iatrogenic harm to gender non-conforming adolescents who would grow up to be lesbian, gay or bisexual:

“Comments by clinicians at GIDS have been recorded saying ‘soon, there will be no gay children left’ due to the excessive number of young people treated who would probably grow up to be LGB,”

Currently gender clinicians are unable to rule out permanent infertility from the combination of puberty blockers started in early puberty followed by cross-sex hormones. Permanent impacts on sexual function are also unknown, raising questions to adolescents’ capacity to consent to the treatment. The email continues: 

“We regard this as anti-homosexual conversion therapy by medical intervention … and would like confirmation that the same, or similar, is not happening here in New Zealand.”

This is a relevant concern. BBC Newsnight journalist Hannah Barnes has detailed the ‘trans the gay away’ reports of whistleblower clinicians in her book Time To Think published earlier this year.  Alongside whistleblower accounts, Dutch clinicians have measured the emerging sexuality of adolescents treated with puberty blockers, showing the vast majority expressed romantic interest in members of the same sex prior to treatment. Canadian research also showed most boys with gender dysphoria in childhood desisted and grew up to be gay when not given blockers.

In New Zealand there are two news reports of iatrogenic harm to young lesbians affirmed as trans and given hormone treatments. In one case reported in the NZ Herald in 2017, Zahra Cooper felt that that the testosterone treatment made her depressed and suicidal. She had become convinced she was a boy born in the wrong body after watching videos on youtube and ruminating on her masculine dress preferences. After a diagnosis of gender dysphoria from a psychiatrist she was prescribed testosterone. But the hormones did not help and Cooper attempted suicide twice. This prompted a reevaluation and autism diagnosis from a second mental health specialist.   

In another case, reported in The Listener in 2021 and highlighted by Professor Paul, a young woman confused her tomboyish preferences with innate male identity at odds with her female sex at age 10. Doctors in NZ affirmed her trans identity and she subsequently took puberty blockers at 14, then testosterone, had a double mastectomy at age 16, and a hysterectomy at 18 before realising that treatments were not helping and suffering profound regret. She still experiences dysphoria and health consequences and the doctors who mistreated her have not been held accountable.

The second email highlighted guidance from Medsafe that Goserelin, an anti-prostate cancer drug used off-label as a puberty blocker, should not be given to children. While the other hormone suppression drug, Leuprorelin, is approved for children but only to treat precocious puberty.

“There is no discussion of the treatment of adolescent gender dysphoria in the Medsafe guidelines,”

The email cites the 2021 systematic reviews by the UK National Institute of Health and Care Excellence (NICE), and the decision that same year at Sweden’s Karolinska university hospital to cease hormonal interventions as routine treatments for youth gender dysphoria after reports of harm to patients on puberty blockers. The email continues:

“I am not opposed to transgender healthcare, I fully support appropriate healthcare for the appropriate people”

The person insisted that the MOH must “conduct its own independent review into the safety of puberty blockers without the conflict of interest of a quasi-medical/lobby group, [such as PATHA].

Again, the content of this particular email is relevant to the MOH decision-making on the rewording draft. In a 14 September email to CCA-CYH Jelleyman, Derek Fitzgerald of Medsafe advises that providing information about a drug in an unapproved indication amounts to advertising an unapproved indication and is a breach of section 20 of the Medicines Act. The clinical advisors remove planned references to Goserelin and Leuprorelin and Fitzgerald is satisfied. However, the legal advice I have is that this may not avoid a breach –the two drugs mentioned above are the only drugs used for this purpose in New Zealand and advertising the class of drugs is effectively advertising the drugs themselves. This point must be emphasised –by providing information on the use of puberty blockers for gender dysphoria without mentioning that the drugs are not approved for this purpose the MOH and now Te Whatu Ora may be in breach of the Medicines Act. The same legal quandary may also apply to Newsroom’s article. The article makes no mention of the unapproved status of puberty blockers and places emphasis on the supposed benefits.

These are the two emails that alerted the MOH to the problems. To my knowledge, all similar prior emails received a form response. Does Newsroom maintain that these emails are anti-trans? Are pointing out the documented cases of harm to young lesbians from puberty blockers and legal issues anti trans arguments? 

Framing the legals issues more directly:
a) If Newsroom discovered and published the names of the particular people that had alerted the MOH to these issues and labelled them “anti-trans activists” would Newsroom be able to avoid defamation action?

b) Has Newsroom consulted legal advisors to ensure that the article’s promotion of a drug for an unapproved indication does not breach S.20 of the Medicines Act?

Naming of sources

The article does not name me or my group Fully Informed but paraphrases our statements. This indicates a bias. Naming me would allow readers to check my work, discover a counter -argument, and decide for themselves. The article breaks with  journalistic convention because it provides a weak defamation workaround and misleads readers by omission contrary to the Media Council principles.

Claim 3: The Cass Review made no recommendations on the use of puberty blockers

The third false claim is that the “interim review” in the UK “made no recommendations on the use of puberty blockers due to gaps in the evidence base”. The article is referring to the “Cass Review” conducted by Dr Hilary Cass (former President of the Royal College of Paediatrics and Child Health) for the NHS. The Review is also known by its full name the “Independent review of gender identity services for children and young people”. Again, the article does not name a source of contrary information. The agenda appears to be to do the bare minimum for “balance”. The article mentions a contrary view but downplays it and disallows the casual reader an avenue for discovering an alternative view in the hope the article can squeak past the Media Council’s balance principle.

However, in this case the claim is plainly false. In her July 2022 letter to the NHS Dr Cass recommended that puberty blockers only be used in the context of a formal research program (emphasis mine):

“In light of these critically important unanswered questions, I would suggest that consideration is given to the rapid establishment of the necessary research infrastructure to prospectively enrol young people being considered for hormone treatment into a formal research programme with adequate follow up into adulthood, with a more immediate focus on the questions regarding puberty blockers. The appropriate research questions and protocols will need to be developed with input from a panel of academics, clinicians, service users and ethicists”

The NHS has published a draft service specification in response to Dr Cass’ recommendation. The specification confirms that puberty blockers will only be used within a formal research protocol (emphasis mine).  

“Consistent with advice from the Cass Review highlighting the uncertainties surrounding the use of hormone treatments, NHS England is in the process of forming proposals for prospectively enrolling children and young people being considered for hormone treatment into a formal research programme with adequate follow up into adulthood, with a more immediate focus on the questions regarding GnRHa. On this basis NHS England will only commission GnRHa in the context of a formal research protocol.”

The draft specification also requires providers make psychosocial support the front-line intervention for children and young people. Social transition (reinforcing the child’s belief that they are the opposite sex) is discouraged due to “the risks of an inappropriate gender transition and the difficulties that the child may experience in returning to the original gender role”. All children and young people considered by the provider will receive a standardised comprehensive assessment including mental health assessment.

The recommendations of Dr Cass and the responding draft service specification present a remarkably different regime compared to the use of puberty blockers New Zealand. In New Zealand, the PATHA guidelines discourage any mental assessments prior to treatment. A single youth clinic in Christchurch was treating 65 out of 100 gender-questioning young people with blockers.  Readers of the article have been misinformed. It is highly relevant to the article that a country with a similar health system but with greater capacity to conduct evidence reviews has chosen to go in the opposite direction; but readers will believe that an obscure “interim review” hasn’t made recommendations and the UK health system is in stasis on this issue.   

I emailed details of the NHS turnaround to Mark Jennings in December, pointing out that PATHA had misrepresented the Cass Review’s recommendations. PATHA claimed in August 2022 that the Cass Review recommendations “...would increase services as well as accessibility and be more similar to how gender affirming care is provided for children and young people in Aotearoa New Zealand”. Another false claim demonstrating PATHA’s unreliability.  It is concerning and surprising that Newsroom subsequently published an article also making a false claim regarding the Cass Review recommendations.  

In addition to making the false claim, Daalder’s wording confuses matters.   

First, the Cass review is not an “interim review” –the Cass Review has published an interim report. Preparation of the final final report is ongoing.

[After a series of confused edits, Newsroom have changed this to “interim report” and mentioned that the NHS restriction of puberty blockers. The interim report does actually make reccomendations on puberty blockers, just not “definitive” ones. In any case it should not matter in which document a reccomendation is made, just that the independent review has made reccomendations on puberty blockers.]

Second, Dr Cass does highlight “gaps in the evidence base” but the article’s phrasing implies that these gaps have prevented Dr Cass from making recommendations. Alongside the false claim that Dr Cass hasn't made recommendations, it suggests to readers that evidence of harm is necessary before making recommendations that restrict treatment. This is backwards. Evidence of a treatment’s safety, efficacy, and “reversibility” is required to make ethical claims to this effect. The “gaps in the evidence base” wholly justify a recommendation for the treatment's restriction and no additional evidence gathering is necessary.

Summary

For the article’s headline and central narrative to be true Newsroom must demonstrate that both the decision to remove the “safe and fully reversible” description was motivated by “pressure” (i.e reducing emails from the public) and that the people who emailed had an antipathy towards transgender people. Neither is true. 

CMO Dr Robyn Carey was not under ‘pressure’, or even aware of a high volume of emails when she made the decision to remove the statement. There was an email campaign but it was two years prior in 2020 and an abject failure. Daalder has invented the “anti trans” narrative because it suits his agenda, using the slur against people without naming them because this makes legal redress more difficult. He does does not use it against named people where legal counteraction is more likely.

Daalder has selectively quoted from the correspondence to fabricate a story of “anti trans” influence using the views of one unqualified official to represent the views of the MOH when more qualified officials disagreed. Many of the recent queries about the statement originated from medical professionals not activists. The actual reason for the change of wording is clear from the correspondence and subsequent MOH media statements. The MOH states that “much of [the article] is false, including the headline”. 

A notable source of contrary information is the Cass Review. The article mentions the Cass Review in obscure terms and makes a false claim to the Review’s recommendations.   

The above is enough for the article to be retracted and for Newsroom to publicly apologise. In the interests of completeness I now turn to parts of the article that are deliberately misleading by omission or commission contrary to the Media Council principles. 

Section II: Misleading material

The use of puberty blockers

“Puberty blockers were pioneered to address a condition called precocious puberty, in which children start to undergo puberty too early. Since the late 1990s, they have also been used to help children questioning their gender identity delay the onset of puberty. This gives them time to decide whether to continue transitioning – at which stage partially irreversible treatments like hormonal care may begin – or to go through puberty.”

There are several problems with this paragraph.

First, the claim that “puberty blockers were pioneered to address a condition called precocious puberty” is misleading. Puberty blockers are a class of drug more precisely known as “Gonadotropin-releasing hormone agonists” (GnRHa) (alternatively known as “Luteinizing Hormone-Releasing Hormone agonists”, LHRHa) with several uses. The drugs were also initially trialled to treat hormone-dependent tumours such as prostate cancer and breast cancer in the late 1970’s and early 1980’s. The treatment of prostate cancer is the most common usage for GnRha in New Zealand, but other usages include the chemical castration of sex offenders (in the US), and endometriosis. The article’s positioning of the related usage for precocious puberty and omission of the other uses makes the use for gender-questioning adolescents appear relatively benign. Would the reader form such a benign impression if the other indications were spelt out?    

Second, the article draws a misleading equivalence between the (partially approved) usage for precocious puberty (typical age 6-10) and the unapproved or “off-label” usage for gender-questioning adolescents (typical age 10-16). Daalder is well aware that we have separate drug approval processes for age groups 5-11, 12-17, and 18+, a feature of the reporting on the covid vaccine. Drug approval processes are separate for these age groups because of physiological differences and potential impacts on “critical windows” of development. When GnRha is used to treat precocious puberty the child (typically aged 5-11) will have puberty delayed until the normal age for puberty at around age 12. But this is not the case for a gender-questioning adolescent treated age 11-16 who will not experience puberty in the normal age range. Sex hormone production may restart with delay but it is unclear if adolescents coming off GnRha treatment at age 16 experience a physiologically equivalent “puberty” from ages 16+, i.e. “delay the onset of puberty”, “...or to go through puberty” as the article claims. The limited scientific literature indicates that this is not the case. The question of the ‘reversibility’ of GnRHa treatment and the critical developmental window of normally timed puberty will be picked up below.

Age group differences mean that GnRha has not been approved for the treatment of gender dysphoria in adolescents in any jurisdiction in the world. As noted in Section I by the “consumer correspondence”, the advice from Medsafe is that Goserelin should not be given to children (i.e it is not even approved for precocious puberty). While the other hormone suppression drug, Leuprorelin, is approved for children but only to treat precocious puberty. The article misleads readers into thinking that scrutiny of GnRha for treating gender-questioning adolescents age 10-16 must be motivated by fear-mongering or prejudice against trans people, when it is Newsroom that is applying a double standard. Newsroom fails to mention the physiological differences of the treatment populations and the “off label” usage –something that Newsroom would not do for other drugs such as the covid vaccine. 

Third, the claim that it gives children “..time to decide whether to continue transitioning” is controversial and questioned by leading gender clinicians. This claim is paraphrased in the title of BBC Newsnight journalist Hannah Barnes’ book “Time to Think'' on the collapse of the GIDs clinic in the UK. Barnes documents how clinicians at GIDS spoke of puberty blockers as a “fully reversible” intervention that gave children “time to think'' inside the clinic. At the same time GIDS Director and clinical psychologist Polly Carmichael was relaying a different message outside the clinic, telling The Guardian “The blocker is said to be completely reversible, which is disingenuous because nothing is completely reversible” in 2015. Carmichael went on to speculate that that the surge of sex hormones at (a normally timed) puberty could “[have] an impact on the trajectory of gender dysphoria”, noting that the most likely outcome for prepubescent child with gender dysphoria who proceeded through normal puberty was an LGB adult, not a trans adult. Blocking puberty prevents these adolescents from discovering their emerging sexuality, potentially preventing them from overcoming the confusion of gender non-coforming preferences for an innate opposite-sex identity that requires further medical intervention. 

The Dutch researchers who pioneered the use of puberty blockers for gender dysphoria have also recently admitted that puberty blockers could be locking the child into dysphoria and a medical pathway: “One cannot exclude the possibility that starting [puberty-blockers] in itself makes adolescents more likely to continue medical transition” [article]. The same point was made by Dr Cass in her letter of recommendations to the NHS

“We do not fully understand the role of adolescent sex hormones in driving the development of both sexuality and gender identity through the early teen years, so by extension we cannot be sure about the impact of stopping these hormone surges on psychosexual and gender maturation. We therefore have no way of knowing whether, rather than buying time to make a decision, puberty blockers may disrupt that decision-making process.”

Taking into account the broader context detailed above, a more neutrally phrased paragraph with the omitted context in blue would read as follows:  

“Hormone blockers were pioneered to treat hormone-dependent tumours such as prostate cancer and a condition called precocious puberty, in which children start to undergo puberty too early. Since the late 1990s Dutch researchers began using blockers to suppress the puberty of children questioning their gender identity. This usage only began in New Zealand since around 2010 but no jurisdiction in the world has licensed puberty blockers for this purpose. Proponents claim that this gives gender-questioning children time to decide whether to continue transitioning. But in a recent article the original Dutch researchers now admit that they “cannot exclude the possibility that starting [puberty-blockers] in itself makes adolescents more likely to continue medical transition”. A point also made by Dr Cass in her letter of recommendations to the NHS. Overseas research indicates that the vast majority of children treated with blockers go on to partially irreversible treatments like cross-sex hormones”. Clinicians in New Zealand do not track long-term outcomes so it is difficult to say if this is also the case here.

Quote from PATHA Vice-President

The next paragraph features a quote from PATHA vice president from Stuff’s September article emphasising that blockers are only used after “careful consideration”.  This paragraph is notable for three reasons.

First, the PATHA vice president is not named in the Newsroom article but is named in the Stuff’s September article as Dr Rona Carroll​. Why not name Dr Carroll here? Naming Dr Carroll allows readers to check Dr Carroll’s past statements on puberty blockers and compare with present statements and the MOH position.

Second, one of those previous quotes from Dr Carroll in Stuff’s September article is the following:

"Puberty will resume if puberty blockers are stopped, and so the effect is therefore reversible…”
 

Why not quote this statement when it addresses the central issue of the article –the safety and reversibility of puberty blockers? Perhaps doing so would now put Dr Carroll at odds with the MOH who point to the “relatively limited and thin evidence available in this area” and this would undermine Dr Carroll’s credibility. Instead the emphasis falls back to the supposed “careful consideration”. But this is incoherent. If the effects are truly reversible then why does the treatment need “careful consideration” before proceeding? Prominent activist group Gender Minorities Aotearoa (GMA) puts this plainly on their website:

“Gender Minorities Aotearoa advocates for the placement of puberty blockers within a similar Harm Reduction framework as contraceptives – that young trans people must be able to access these completely reversible medical treatments without barriers” 

This is wrong but at least it is logically consistent. A neutral article would have pressed Dr Carroll on this contradiction.

Third, is the question of whether NZ clinicians actually are ‘carefully considering’ the aetiology of the child’s distress, the uncertain benefits and harms, and the adolescent's capacity to consent prior to prescribing puberty blockers. We have one documented case of clinicians failing a young lesbian in this regard in Section I. Whistleblower clinicians at GIDS also believed that this was not always the case with at least one case of a patient receiving verbal assurance they would be prescribed blockers on the first appointment, and others after only two sessions. Whistleblower case manager Jamie Reed claims that ill-considered fast-tracking of medical intervention was the norm at Missouri clinic. What is special about New Zealand that would prevent this from happening here? A major theme of Time to Think is the pressure GIDS clinicians felt to initiate medical intervention from activist transgender charities like Susie Green’s “Mermaids”. GMA appears to play a similar role here going as far as to issue their own Guide for Patients.     

A neutral article would have asked Dr Carroll for evidence of “careful consideration”. Specifically the number and proportion of adolescents who are refused blockers after assessment and fail the “careful consideration” process. 

WPATH editorial and “Reversibility”

The next couple of paragraphs quote from a WPATH authored editorial in the International Journal of Transgender Health. On the question of the reversibility of puberty blockers the quoted portion of the editorial says “...whose effects on pubertal development are considered reversible according to the current literature”. “[C]onsidered reversible”, “according to the current literature” – (emphasis mine) hardly the most confident of statements and notably less confident than Dr Carrol. An unbiased article would have questioned which ‘current literature’ WPATH is referring to and whether ‘future literature’ might provoke an ‘evolving position’ on this question.  

The WPATH editorial cites one journal article to support the “considered reversible” claim, Panagiotakopoulos et al. (2020). When we examine Panagiotakopoulos et al (2020) for supporting evidence of puberty supression’s reversibility we find it does not have any but cites another article by the same author, Panagiotakopoulos (2018).    

At this point its is useful to note that the literature on puberty blockers can be ambiguous and uses “fully reversible” in two senses: 

1. The direct impacts of sex hormone production is reversed, i.e sex hormone production restarts. 

2. The patient suffers no long health impacts. Impacts on the patient’s brain, sexual function, and bone development “reverses”, i.e development ‘’catches up’ to where it would have been without puberty suppression. 

The first sense is not controversial. Sex hormone production does restart. But lay parents are not interested in the complexities of the endocrine system and it is the second “no long term impacts” sense where there is disagreement. It is also clear that Dr Carroll meant “reversible” in the “no long term impacts'' sense. 

Picking up our citation chain, Panagiotakopoulos (2018) discusses the proposed “reversibility” of puberty suppression in both senses: In the first sense: “Initiation of therapy produces a decrease in gonadotropins…and eventually endogenous sex steroid levels, an effect that is reversible upon discontinuation of treatment”. But in the second sense Panagiotakopoulos does not draw any firm conclusions noting the mixed results of two (!) studies (also mentioned below) that tracked patients bone mineral density after treatment was discontinued. In one study “had not completely reversed after 6 years of cross-sex steroids.” 

In other words, when we follow the citation chain the WPATH editorial’s “considered reversible” is not supported in the “no long term impacts” sense and is relying on ambiguity, citation laundering, and credulous journalists to further their aims.  

Professional bodies

The article then lists a number of professional bodies that support “[t]reatment of transgender youth with puberty blockers”. The reader’s impression of this section is that puberty blocker treatment represents a consensus amongst the medical community.

There are several problems with this section. 

First, puberty blockers are not given to “transgender youth”, they are given to youth with gender-related distress who are anxious about puberty. The distinction is important because “transgender youth” frames access to puberty blockers as a civil right, to which people with this status are entitled. This is contrary to Medical Council guidelines which specify that a diagnosis is required before medical intervention can be prescribed. We also do not know if the adolescent patient’s trans identity is stable or representative of a life-long transgender status. The Cass Review interim report highlights the complex aetiology of gender-related distress, including sexual abuse, LGB sexualities, and autism; and how distress can resolve and gender identity can change without medical intervention. It is biased and irresponsible to label all adolescents receiving the treatment as “transgender youth” when that is not the case. Elsewhere the article does use the phrase “children questioning their gender identity” in another paragraph which is fairly neutral. Other  neutral terms refer to “gender-related distress” or “gender-questioning”.     

Second, the article fails to list the Royal Australia New Zealand College of Psychiatrists (RANZCP) and their position statement on gender dysphoria. The statement highlights the “paucity of evidence” in this area and positions psychotherapy without medical intervention as a valid approach that psychiatrists might take. This is at odds with PATHA and some of the other medical bodies. Why isn’t the reader informed about a major medical professional body with members in New Zealand taking a contrary view? There are other medical bodies such as the Association of Clinical Psychologists (UK) and the National Association of Practising Psychiatrists (Australia)  that do not support medical intervention as the frontline treatment. The article leaves the reader with the impression that only a small number of cranks would oppose puberty suppression.

Third, one of the listed organisations that supposedly supports medical intervention on adolescents is the American Academy of Pediatrics (AAP). However, a Wall Street Journal article in 2021 reports that the AAP’s support for puberty blockers is controversial in the rank and file of the AAP’s membership. The AAP was asked to “re-evaluate its commitment to affirmative care in light of the growing international skepticism about this treatment protocol for children and adolescents” in formal resolution. “80% of responding pediatricians indicated that they supported it” but the AAP leadership stifled debate and the resolution was pulled. Under pressure to account for this, the AAP leadership authored an op-ed in the WSJ last year. They stated that the “vast majority” of children or adolescents presenting to clinics should not be receiving “medical treatments or surgery”. It is now not clear what the AAP does or does not support. [The AAP is now being sued by a detransitioner “alleging civil conspiracy, fraud, and medical malpractice”]

This section needs to be rewritten to adopt more neutral language to describe the patients receiving treatment, mention the RANZCP, and Swedish, Finnish, UK health authority positions, and include the AAP controversy. The key distinction between the groups that have conducted systematic evidence reviews and groups that have merely adopted a resolution needs to be mentioned (as detailed in Section I).      

Impacts of Puberty Blockers and “Reversibility”

The article mentions a potential negative health impact of blockers and downplays it:

“PATHA's guidelines acknowledge prolonged use of puberty blockers may have effects on bone density and development but offer ways to manage this risk. Side effects are common in an array of other medications that aren't used to treat transgender people as well.”

This paragraph is troubling and misleading for several reasons. The phrasing that the PATHA guidelines “offer ways to manage this risk” implies that if the adolescent is advised to take vitamins and perform loading bearing exercise then bone health impacts will not eventuate. The following subsections detail the existing evidence, case reports, and expert opinion on the negative health impacts of puberty suppression. The paragraph is medical misinformation and should be retracted with clarification.

Bone health

Daalder does not appear to be aware of the scientific literature of the bone health impacts or of the growing number of reports of adolescents developing osteopenia or osteoporosis and other permanent health impacts after treatment with blockers. 

In Sweden a 14 year old “Leo” was diagnosed with osteoporosis after 4.5 years of puberty suppression. Leo reports constant back pain. An investigative news team found 12 other adolescents with impacts such as worsened mental health and liver damage from hormone treatments. 

Hannah Barnes reports a young adult patient previously on blockers that now has osteoporosis. The patient’s doctor believes that “there are others with cases like mine”.

Also in the UK 16 year old “Jacob” began on blockers at age 12. Jacob claims that taking blockers was “the worst decision I’ve ever made…I go to school and I feel like other people are developing and I still feel like a child…I’d never broken a bone before [taking puberty blockers],” he says. “I’ve since broken four bones. “I stubbed my toe, it broke. I fell over, my wrist broke. Same with my elbow.””

The New York Times reported on the issue in November last year and highlighted the case of a teen who developed osteoporosis after 2 years on blockers. The Times commissioned an analysis of seven studies of the bone health impacts from puberty suppression and any recovery after treatment withdrawal. The analysis shows that bone health does not recover in many patients:

“Many doctors treating trans patients believe they will recover that loss when they go off blockers. But two studies from the analysis that tracked trans patients’ bone strength while using blockers and through the first years of sex hormone treatment found that many do not fully rebound and lag behind their peers.”

““There’s going to be a price,” said Dr. Sundeep Khosla, who leads a bone research lab at the Mayo Clinic. “And the price is probably going to be some deficit in skeletal mass.””

The two studies mentioned are likely Schagen et al, (2020) and Klink et al. (2015). No studies have addressed patients who come off puberty blockers and do not receive cross-sex hormones. In the Klink et al. study follow-up was 5 years after puberty blocker withdrawal but most male subjects still had bone health scores below pre-treatment levels. In another study, Biggs analyses data from a GIDS puberty suppression cohort and finds that up to a third of patients have abnormally low bone density. Combined with an elevated fracture history (not reported) these levels would meet the diagnostic criteria for paediatric osteoporosis (25). There are no studies demonstrating a complete recovery in the majority of subjects.      

Subjects enrolled in these observational studies received the same advice offered in the PATHA guideline. The article’s suggestion that this advice adequately ‘manages’ the risk when it demonstrably does not is medical misinformation and must be retracted with a formal clarification. 

To make a claim of safety and reversibility proponents of puberty blockers must present evidence to that effect. Without evidence either way it would be unethical and misleading to make a positive claim of safety. But we have moved beyond that now. With these results there is now increased certainty that the puberty blockers are harmful and not “reversible”. 

Bone health is one of the better studied impacts of puberty suppression. Other health impacts such as sexual and cognitive function are less well studied but that does not mean the risks are not present, or that informed consent processes, or articles discussing the impacts can omit to mention them. 

Sexual function and Fertility

The article never mentions impacts of puberty suppression on sexual function or fertility, instead highlighting potential impacts on sexual function if the adolescent does not receive blockers.

Puberty suppression of male subjects at Tanner stage II (onset age 9-14) plus ongoing anti-androgen treatment may effectively sterilise subjects and few take up fertility preservation prior to treatment (26). 

A case in the UK reports reduced sexual function “Two years on, since coming off the blockers [at age 18] Alex has still not experienced any sexual feelings”. 

Marci Bowers, the current WPATH president and a vaginoplasty surgeon has warned that if male adolescents have puberty blocked from early puberty and then go on to further treatments they may never achieve orgasm as an adult. A related impact is the stunting of genital growth in males which limits the options for any future vaginoplasty. This impact is mentioned in the PATHA guidelines but the full implications are never spelt out. Without sufficient penile and scrotal skin for the penile inversion technique surgeons must use another technique which refashions a section of the patients intestine into a neovagina. The latter technique has a higher complication rate. The original Dutch study, –ostensibly demonstrating puberty suppression’s benefits–, reported that one subject later died from intestinal vaginoplasty complications. An indirect consequence of previous puberty suppression (8,27).

Cognitive function

Puberty is also a period of brain maturation and its suppression may disrupt brain development. The article and the PATHA guidelines omit to mention impacts on cognitive development. This omission from the PATHA guideline violates Right 6 of the Code of Health and Disability Services Consumers' Rights “Every consumer has the right to the information that a reasonable consumer, in that consumer's circumstances, would expect to receive…”.  Obviously this includes impacts that are uncertain or where there is limited research.  

An animal study of puberty suppression finds “likely permanent” impacts to long-term spatial memory and highlights the “critical window” of a normally timed puberty for the development of cognitive function. The researchers note the applicability of their findings to human adolescents (16). A case study of an 11 year old child who had puberty suppressed for 22 months showed a 10 point drop in IQ which persisted at follow-up 11 months after treatment withdrawal (17). Studies of GnRHa use for precocious puberty show a 7 or 8 point drop in IQ (28). Dr Cass draws attention to the potential impacts of puberty suppression in her letter of recommendations to the NHS: 

“A further concern is that adolescent sex hormone surges may trigger the opening of a critical period for experience-dependent rewiring of neural circuits underlying executive function (i.e. maturation of the part of the brain concerned with planning, decision making and judgement). If this is the case, brain maturation may be temporarily or permanently disrupted by puberty blockers, which could have significant impact on the ability to make complex risk-laden decisions, as well as possible longer-term neuropsychological consequences. To date, there has been very limited research on the short-, medium- or longer-term impact of puberty-blockers on neurocognitive development”

Given the above, the article’s phrasing that “[s]ide effects are common in an array of other medications that aren't used to treat transgender people as well” is glib. This sentence is uninformed opinion masquerading as reporting and designed to lead the reader into thinking that concern about the health impacts of puberty suppression must stem from prejudice against trans people.

I ask Newsroom to name medications that are given to physically healthy adolescents that have the range and severity of potential health impacts described above. The only medication that comes to mind is chemotherapy but that is given to adolescents in life or death situations. If Newsroom fails to name such a medication in their response to this complaint I will take that as an admission that the phrasing is misleading and should be retracted. 

Politicisation

“Puberty blockers have also come under attack from non-professionals, including Republican politicians in the United States who have passed legislation which would remove transgender youth from their parents' care if they are given puberty blockers.”       

The paragraph is factually correct (as far as I know), and indeed the treatment of gender-questioning adolescents has become politicised. However, it omits the other side of the political equation and uses emotive language. The paragraph further misleads readers to the motivation of those questioning or critiquing the use of puberty blockers –right wing partisans rather than advocates of evidence based medicine . 

The article describes criticism of puberty blockers as an “attack”. 

The article omits that the Victorian Human Rights Commission in Australia (incorrectly) classifies a parent not consenting to treat their child with puberty blockers as a “prohibited practice” under the State’s conversion therapy prohibition law –a move that intimidates parents into complying with clinicians or their child’s wishes. 

Also in Australia, a teenager was removed from parent’s care because a court deemed their refusal to consent to cross-sex hormone treatment to be “abusive”. The parents… 

“..knew their daughter had been depressed and in need of help, but they wanted an independent psychologist to consider all possible underlying causes, not just gender issues, and to look into non-invasive treatment options.”

Therefore it is one-sided to report solely on legislation that may result in children being taken into care for providing hormonal treatments when the reverse (a child removed from parents’ custody for not consenting to treatments)  has actually happened in a nearby jurisdiction.   

The article also omits moves of the health authorities of Sweden and Finland to restrict access to puberty blockers. These moves were initiated by health authorities not legislators and under left wing governments. 

Supposed Benefits

“The use of puberty blockers is associated with lower rates of depression, anxiety and suicidality in young people between six and 18 months after starting treatment.”

This paragraph fails to mention the marginal effect sizes, failure of replication, and lack of control in the studies purporting to show mental health benefits of puberty blockers. The Swedish , Finnish and UK (NICE) systematic reviews address the question of mental health benefits and find (in the case of the NICE review, emphasis mine):

“The results of the studies that reported impact on the critical outcomes of gender dysphoria and mental health (depression, anger and anxiety), and the important outcomes of body image and psychosocial impact (global and psychosocial functioning) in children and adolescents with gender dysphoria are of very low certainty using modified GRADE. They suggest little change with [puberty blockers] from baseline to follow-up. Studies that found differences in outcomes could represent changes that are either of questionable clinical value, or the studies themselves are not reliable and changes could be due to confounding, bias or chance.”

Why has Daalder picked from low quality studies and not the higher quality systematic reviews? It is important to emphasise that none of the studies purporting to show mental health benefits have a control, meaning the entirety of the reported benefit could be the placebo effect. We would also expect the placebo effect to be large for a young vulnerable population who understand the treatment as the beginning of their ‘gender journey’. 

As it stands, homoeopathy has some randomised controlled trials demonstrating a mental health benefit. The evidence for a mental health benefit from homoeopathy is therefore of higher quality than for puberty blockers. However, when accounting for publication bias and study quality the benefits wash out in systematic review.    

Would Newsroom report on the association of homoeopathy treatment with improved mental health, and quote approvingly from homoeopathy advocates without noting the study quality problems? If Newsroom responds in the negative or does not answer this question I will take that as an admission that the paragraph is biassed and should be revised. 

Summary and Requested Clarification

The subject matter does not suit a “drive by journalism” style article. As the Media Council has noted the issue is “a sensitive, complicated, and important topic, where there appears to be evolving scientific debate.”   

Aside from the factual errors, the article is severely biassed. The article misleads readers by omission or commision to the risks and benefits, evidence for, Medsafe-approval status, and institutional support of a medical treatment; and motivations of those who critique the treatment. By providing (misleading and promotional) information about a treatment for an unapproved indication the article may breach S. 20 of the Medicines Act. The organisation that prosecutes Medicines Act breaches is the MOH –the same organisation that describes the article as “false”.  

I request the article be retracted and a formal and public apology to myself and Fully Informed be issued alongside a clarification of the article’s errors and misleading statements.

The clarification should cover:

• The decision of the CMO Dr Carey to remove the statement and the decision’s timing 3 weeks prior to being made aware of the volume of queries. 

• The timing and failure of the Fully Informed email campaign. 

• The lack of medical qualification and inexperience of the official that believed the statement was “no doubt true”. 

• The qualifications of the clinical advisors who did not believe the state was appropriate. 

• The queries raised by GPs.

• The content of the two emails that alerted the officials to the legal issues and lack of evidence. 

• The cases of young LGB people in the puberty blocker literature and reported in the news who have mistakenly believed they were trans and been treated and harmed by hormonal treatments.  

• The lack of evidence for anyone who emailed holding antipathy towards trans people.

• The actual motivation of people who have written to the MOH, such as myself –the concern that standards of evidence-based medicine do not seem to be applied in this area. 

• The recommendations of the Cass Review to restrict puberty blockers to medical research due to evidence gaps. 

• The Swedish and Finnish systematic reviews and their occurrence under left-wing governments and the similar moves to restrict blockers to trials.

• The important distinction between a systematic review on the one hand and a literature review and cherry-picked studies on the other.

• The use of GnRha for prostate cancer and the chemical castration of sex offenders and its unapproved status in New Zealand or any jurisdiction for gender-questioning adolescents. 

• The possibility that treatment with blockers “in itself makes adolescents more likely to continue medical transition” as discussed by the gender clinicians that pioneered the treatment. 

• The legal implications of advertising the availability of a medicine for an unapproved indication in regards to S.20 of the Medicines Act as pointed out by a Medsafe official.

• The distinction between its use for precocious puberty (age 6-10) and gender questioning adolescents (age 10+), the “critical window” for brain, sexual function, bone mass accrual, and fertility.

• The ambiguity of the term “reversible” and the lack of confidence and evidence for “fully reversible” in WPATH’s statements. 

• Name Dr Carrol as the vice-president of PATHA .

• The lack of requirement to hold a medical qualification for membership in PATHA and WPATH. 

• The RANZCP position on the evidence for medical interventions and the support of the RANZCP for non-medical approaches. 

• The criticism of the WPATH and Endocrine Society guidelines by notable experts in evidence-based medicine. 

• The confused position of the AAP on the issue. 

• The research literature on bone health impacts, demonstrating that the treatment is not “reversible” as a layperson would understand, that health impacts can be permanent and can occur while the patient is still a teenager. 

• The potential impacts on sexual and cognitive function as well as fertility when continued on. 

• The Cass Review’s highlighting of potential impacts on cognitive function. 

• The chilling effect of interpretations of the conversion therapy prohibition laws in regards to parental consent to treat with puberty blockers.

• The lack of controls in studies purporting to show a mental health benefit and the possibility that all reported benefit is the placebo effect.  

In addition, Daalder must delete the tweet promoting the article and issue a clarification
that: 

• The email campaign was in 2020 (not “last year”).

• Only one official with no medical qualifications believed the statement to be true (not multiple “officials”), and that other officials with medical qualifications disagreed. 
  [Daalder has since deleted the tweet but has not issued any clarification]

  
  
  

Dear Director General of Health,

I am the spokesperson for the group Fully Informed. We advocate for the right of patients and their parents to have accurate and understandable information on puberty blockers. We are pleased that the Ministry set in motion an evidence brief on puberty blockers late last year. The public, the patients, and their parents have been poorly served by the available practice guidelines and consent forms, as well the previous wording on the Ministry’s own website that puberty blockers were “safe and fully reversible” – a claim that senior clinical advisors now believe to be inappropriate.

There are recent systematic evidence reviews of puberty blockers (1,2), the findings of which could be usefully summarised and presented to the public with the Ministry’s imprimatur. We look forward to the Ministry’s support of the rights of consumers to receive accurate and understandable information on their treatment options and the public becoming better informed on this issue.

The evidence brief was originally due to be released around the middle of this year. However, on 22 August, the Ministry published a statement notifying the public that they are expanding the scope of the puberty blockers evidence brief “to include studies regarding mental health and wellbeing outcomes” and delaying the release to later in the year, after the election.

The statement and the timing for the evidence brief release at the end of this year raises some questions. 

First, while the original scope of the evidence brief was the “safety, reversibility, and long-term clinical outcomes of puberty blockers for gender-dysphoric adolescents”, the expansion of the scope to include mental health and wellbeing outcomes is confusing as these should have  already been included in the “long-term clinical outcomes” focus. However, to our knowledge there are no long-term studies reporting clinical mental health outcomes. There are some low quality, short-term studies of subjective self and parent reports of mental health outcomes with mixed results. The evidence reviews systematically evaluate these studies and conclude that the evidence for mental health improvements following puberty suppression is inconclusive.

The Ministry’s statement suggests that the Ministry may:

1. Be intending to report the mental health outcomes results of the systematic reviews (i.e. that are inconclusive).

2. Be intending to report a selection of results from the short-term studies directly.

3. Need an excuse to delay the release of the evidence brief beyond the election.
   

(1) would be entirely appropriate, (3) is understandable (though see my point about delays below). However, (2) is questionable and would undermine the Ministry’s reputation and to the integrity of New Zealand’s Science Advisory System for reasons which I outline below. I seek clarification from the Ministry that scientific integrity is paramount.

If the Ministry was planning on reporting on a selection of results from low quality, short-term satisfaction / psychosocial outcome studies of distressed teenagers, then:

1. How will the Ministry select the studies to report on? For example, will the Ministry report the results of Carmichael et al, (2021) (3) which found no change in psychological function, or the results of Costa et al, (2015) (4) which found no statistically significant differences between the group given psychosocial support together with  puberty suppression and another group given psychosocial support only? 

2. Will the evidence brief make the causality of the results clear? i.e. whether the results are attributable to the puberty suppression intervention, concurrent interventions such as psychosocial support, the placebo effect, or regression to the mean? (5)

3. Will the Ministry evaluate and report on the quality of studies and situate them within an evidence hierarchy? 

As the Ministry knows, systematic evidence reviews mitigate the bias of the above issues. Systematic reviews work on the basis of an “hierarchy of evidence” – observational studies are unreliable in the evaluation of treatment effects specifically and replication of findings by controlled trials is necessary before firm conclusions can be drawn about a treatment’s effectiveness.

I make an OIA request for Ministry documents or policy that reference or describe the “hierarchy of evidence” or similar and how it applies to Ministry decision-making and reporting.

Unfortunately, the use of low quality studies to support pre-determined views is already common in this area of medicine, including the so-called “Standards of Care: Version Eight (SOC8) published by the World Professional Association of Transgender Health (WPATH). The SOC8 guidelines are highly unusual and are more appropriately seen as a legitimation exercise than a scientific document. Chapter 9 of SOC8 recommends that eunuch-identified males receive castration, minimum age requirements for surgery were hurriedly removed prior to publication, and WPATH is currently under a subpoena by the state of Florida to reveal communications related to the development of the guidelines – an action that would not be needed if WPATH had a commitment to transparency and the scientific process. It is, of course, unthinkable that the Ministry would endorse these controversial guidelines or their derivatives. 

Second, the Ministry may not be aware that the Cass Review also plans to release followup research on approximately 9,000 gender dysphoric adolescents who have attended the Gender Identity Development Service towards the end of this year (including approximately 1,000 treated with puberty blockers). Unlike the subjective measures mentioned above, this research will have access to NHS patient records and be able to report on more objective long-term clinical outcomes such as fractures, antidepressant use and so on encompassed by the original, and current scope of the evidence brief.

It would be highly embarrassing and confusing if the Ministry were to report positive mental health outcomes from a potentially biassed subset of low quality studies, while at the same time the Cass Review was to release research reporting negative outcomes from the largest, highest quality observational study to date. Parents of adolescents treated with puberty blockers would no doubt have questions for the Ministry if this were to happen. 

In the interim the Ministry may wish to review the medical claims about puberty blockers made by PATHA executive member Dr Rachel Johnson. The Ministry is in the process of reviewing the evidence and is in a good position to judge if these claims withstand scientific scrutiny and present a full and accurate picture of the evidence. It is odd that Dr Johnson has taken the lead in creating an evidence brief of her own when she presumably knew that the Ministry would soon be publishing an ‘official’ one. Rather than duplicating (or perhaps even contradicting) the Ministry regarding the existing evidence literature, it would be more useful if Dr Johnson could provide the Ministry with follow-up data on the adolescents treated with puberty blockers at her clinic. Despite the usage of puberty blockers for gender dysphoria for over a decade in New Zealand clinicians have not yet provided any follow-up data, and Dr Johnson’s more direct contribution here would be welcome.

If the Ministry judges Dr Johnson’s presentation of the evidence literature to be unbalanced, then the Ministry must take responsibility for delaying the evidence brief and allowing actors with conflicts of interest to fill the information vacuum. The Ministry may also wish to consider the adequacy and ethics of the current line that “[d]ecisions on the use of puberty blockers are best made by patients and their families in consultation with appropriate clinicians” when one of the “appropriate clinicians” is presumably Dr Johnson.

References

1. Ludvigsson JF, Adolfsson J, Höistad M, Rydelius PA, Kriström B, Landén M. A systematic review of hormone treatment for children with gender dysphoria and recommendations for research. Acta Paediatr [Internet]. [cited 2023 Apr 19];n/a(n/a). Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/apa.16791

2. NICE. Evidence review : Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria. 2020;(October).

3. Carmichael P, Butler G, Masic U, Cole TJ, de Stavola BL, Davidson S, et al. Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK. Santana GL, editor. PLoS ONE. 2021 Feb 2;16(2 February):e0243894.

4. Costa R, Dunsford M, Skagerberg E, Holt V, Carmichael P, Colizzi M. Psychological Support, Puberty Suppression, and Psychosocial Functioning in Adolescents with Gender Dysphoria. J Sex Med. 2015;12(11):2206–14.

5. Clayton A. Gender-Affirming Treatment of Gender Dysphoria in Youth: A Perfect Storm Environment for the Placebo Effect—The Implications for Research and Clinical Practice. Arch Sex Behav. 2023 Feb 1;52(2):483–94.

Background

The issue has been developing for some time with New Zealand at the leading edge of liberalising access to cross-sex hormones and puberty blockers for adolescents. Doctors start these treatments at earlier ages and treatments are increasingly delivered through the primary care system (1). Other jurisdictions, notably Finland, England, and Sweden, have conducted reviews, done an about turn, and moved to restrict access. The contradiction between these directions makes it difficult for New Zealand commentators to maintain a pseudo-consensus  –that the treatments are beneficial, with uncertain but low risks, “affirm” the true nature of the child, and promote mental health.

The pseudo-consensus began to fray with the publication of a handful of articles. Two recent examples were authored by public health researcher Dr Sarah Donovan and Emeritus Professor of epidemiology Charlotte Paul –both in August last year. Donovan’s piece received pushback that it was somehow bad faith to “ask questions” and Palethorpe was given an op-ed in response. Oddly, Paul’s detailed article pointing to documented harms of the treatment in one New Zealand case, and the lack of evidence for the ministry of health’s description of puberty blockers as “safe and fully reversible”, never received the same level of pushback. This is perhaps because the article does not just ask questions, but suggests some rather damning answers; or perhaps because it is difficult to construe a professor of epidemiology as lacking expertise. Proponents of medical intervention seem to prefer frame critics as “anti trans” cranks motivated by confused bigotry.

In September 2022 the ministry removed language describing puberty blockers as “safe and fully reversible” with officials’ correspondence obtained through the Official Information Act response revealed that senior clinical advisors believe that the statement was not supported. 

The change in advice was initially reported as technicality, and that the ministry still endorsed the PATHA guidelines which use similar language. Then in March 2023 journalist Marc Daalder of Newsroom latched on to the fact that in one ministry email a non-clinical advisor with no medical qualifications believed the former advice was true but suggested, after the decision had already been made, that it could be changed to reduce the queries from doctors and members of the public. On the slimmest of footings the article promoted a conspiracy theory that “anti-trans activists” had influenced the ministry to remove supposedly accurate medical advice. Daalder’s story has since been updated three times due to several inaccuracies, Daalder has also deleted the tweet promoting the article, and the article is now the subject of a Media Council complaint.  

For its faults, the Newsroom article did flush out the ministry’s revised view withdrawing endorsement from the PATHA guidelines, and the ministry has pushed back firmly against the suggestion that the burden of correspondence had played a part in the decision, instead citing the recent systematic evidence reviews in Europe as the reason.   

Rivers' piece in the New Zealand Herald also used the ministry removal of the "safe and fully reversible" description as a starting point, and detailed the reasons why the advice was dubious and the clinical practice in New Zealand is reckless. Palethorpe responded quickly by publishing his complaint and encouraged social media followers to write to the Herald asking for retraction. Palethorpe relies on bluster and bravado and, as will be shown below, his complaint is a paper tiger. 

The fact that Palethorpe, hardly someone with relevant qualifications or experience, is one of the most active defenders of early medical intervention in adolescents raises questions about how the public debate in New Zealand will develop. PATHA leadership have been a step removed preferring to issue bland statements rather than engage directly. So far no New Zealand journalist has yet asked PATHA probing questions because PATHA will only work with journalists when they are confident of getting patsy questions, and it has never occurred to some journalists to challenge PATHA’s claims.

The keen observer will now realise that there is now daylight between the positions of PATHA and the ministry. Daylight that may grow wider when the ministry publishes and evidence brief due this month. If the evidence brief is in line with those of England, Finland and Sweden, it remains to be seen how the proponents of medical intervention and their media proxies will take this news.

Claims:

Palethorpe’s modus operandi is to either make a blatantly false claim knowing that the majority of readers will never check for themselves, or to make a tangential point that he would prefer Rivers to have made and then claim that the absence of this point means that Rivers is being deliberately misleading. I label the former a “false”, and the latter as “red herring”

1. The Ministry of Health has confirmed that they retain confidence in the safe and reversible nature if puberty blockers

False. Palethorpe has now acknowledged that the ministry does not retain confidence in the safety and reversibility of puberty blockers. While the ministry has made no public announcement, information that an evidence review is due this month has been supplied to journalists and is an OIA response published to the ministry’s website.

2. The NICE study did not find “evidence for the use of puberty blockers is poor”.

False. NICE did indeed find the “evidence for the use of puberty blockers is poor”.
The NICE review examined eight studies looking at bone health and mental health impacts  of puberty blockers. The NICE review labels all eight of the studies as “[o]verall quality is assessed as poor.” (2)

Contradicting himself, Palethorpe then outlines some of the reasons why the evidence is poor: the lack of control groups, small populations included in the studies and the difficulties with human experimentation. Not mentioned is the high number of participants lost to followup (2)

3. According to Palethorpe, Rivers paraphrased a particular sentence in Dr. Abassi's editorial in the British Medical Journal on the risk of overtreatment to avoid discussing the draconian laws against medical intervention in some US states.

False. Red herring. The main themes of Dr Abassi’s editorial are the challenges faced by health professionals in providing care to young people with gender dysphoria, the importance of evidence-based care, the risks of overtreatment, and prioritising research to address the evidence void.

Abassi mentions the risk of overtreatment three times, it is one of his main themes. By highlighting that clinical guidance is not supported by evidence and the risk of overtreatment, Rivers isn’t paraphrasing a particular sentence, she is summarising two of the main points of the editorial. Palethorpe would prefer Rivers to focus on the draconian laws, but this is a minor detail of the editorial and in an opinion piece Rivers is under no obligation to comply with Palethorpe’s preferences. Palehorpe’s claim that a particular sentence has been paraphrased is false and serves only to distract the reader from Rivers’ point.

4. Palethorpe believes that his search of Media Council rulings is complete and that Rivers has made up the claim that the “Media Council recognises there is a legitimate debate.”

False. The ruling is here “Fern Hickson against the Nelson Mail”, September 2022 and the relevant section is quoted below”

“However coverage of the debate about the treatment of gender dysphoria in children is slightly different. This is a sensitive, complicated and important topic, where there appears to be evolving scientific debate. The Council rejects Stuff’s argument that it is analogous to climate change. In the case of climate change there is an overwhelming consensus of scientific opinion, whereas on the issue of childhood gender dysphoria there seems to be a variety of genuinely held and differing opinions internationally.”

5. Palethorpe claims that Rivers is deliberately misleading by not mentioning that one of the two drugs is approved for children in another indication (age 6-11) 

Red herring. Palethorpe never addresses Rivers' point that the manufacturer of Goserelin, one of the two drugs used off label to suppress puberty, explicitly advises against its usage in children.   

Pharmac has not approved either Goserelin or Leuprorelin for adolescents with gender dysphoria in the normal age of puberty (11-16). Palethorpe attempts to distract the reader by pointing out the Leuprorelein is approved for another indication (precocious puberty, age 5-11), but this is inconsequential to the point at hand.

Drug approval processes are separate for these age groups because of physiological differences (3) and potential impacts on “critical windows” of development (4). When puberty blockers are used to treat precocious puberty the child (typically aged 5-11) will have puberty delayed until the normal age for puberty at around age 12. But this is not the case for a gender-questioning adolescent treated age 11-16 who will not experience puberty in the normal age range. Sex hormone production may restart with delay but it is unclear if adolescents coming off treatment at age 16 experience a physiologically equivalent “puberty” from ages 16+. The limited scientific literature indicates that this is not the case (5–7).

Palethorpe makes much of the fact that both drugs are “open listed”, but that simply means that doctors do not need to request special authority to prescribe off-label.  Doctors have leeway to prescribe unapproved drugs as long as the physician provides all the information that a patient would expect to know about a treatment, information on alternatives, and ensures that the patient has the capacity to understand the information and the potential consequence of the treatment. It is not clear that these latter conditions for prescribing puberty blockers “off label” are being met and common practice may be unlawful. The divisional court in the UK found that it would be “highly unlikely” for a child 13 or younger to be able to consent to puberty blockers. The judgement was overturned on appeal, but on a point of jurisdiction, not disagreement with the divisional court on specific points regarding consent.    

Questions of lawfulness aside, Rivers’ point is that if the drugs are unapproved for usage in gender dysphoria, and one of the drug manufacturer’s of one of the drugs explicitly warns against its use for children, then that adds further weight to withdrawing advice that the usage is “safe and fully reversible”. Palethorpe presents no arguments against this point.

6. Palethorpe disagrees with Rivers' emphasis on the abnormally low bone density found in some patients after puberty suppression. Palethorpe suggests that the issue has been covered because it is mentioned in consent forms.

Red herring. If a substantial proportion of treated adolescents end up with abnormally low bone density, and do not recover, or only partially recover post-treatment then then the treatment cannot be described as “reversible” –the main question addressed in the article. The fact that clinicians are aware of potential bone health consequences, mentioning this in consent forms, but continue to promote the treatment as “reversible” demonstrates the incoherence of their position. The reference for the analysis of academic research is Biggs (2021) (8) which is an analysis of the data in Joseph et al. (2019) (9) both published by the Journal of Pediatric Endocrinology and Metabolism. In up to a third of patients, the bone health measures were so low that combined with an elevated fracture history (not reported) these levels would meet the diagnostic criteria for paediatric osteoporosis. 

Palethorpe does not appear to be aware of the scientific literature of the bone health impacts or of the growing number of reports of adolescents developing osteopenia or osteoporosis, the fact that many subjects do not recover their pre-treatment bone health many years after treatment withdrawal, and other permanent health impacts after treatment with blockers. 

In Sweden a 14 year old “Leo” was diagnosed with osteoporosis after 4.5 years of puberty suppression. Leo reports constant back pain. An investigative news team found 12 other adolescents with impacts such as worsened mental health and liver damage from hormone treatments. 

BBC Newsnight journalist Hannah Barnes reports a young adult patient previously on blockers that now has osteoporosis in her book Time To Think. The patient’s doctor believes that “there are others with cases like mine” (10).

Also in the UK 16 year old “Jacob” began on blockers at age 12. Jacob claims that taking blockers was “the worst decision I’ve ever made…I go to school and I feel like other people are developing and I still feel like a child…I’d never broken a bone before [taking puberty blockers],” he says. “I’ve since broken four bones. “I stubbed my toe, it broke. I fell over, my wrist broke. Same with my elbow.””

The New York Times reported on the bone health issue in November last year and highlighted the case of a teen who developed osteoporosis after 2 years on blockers. The Times commissioned an analysis of seven studies of the bone health impacts from puberty suppression and any recovery after treatment withdrawal. The analysis shows that bone health does not recover in many patients:

“Many doctors treating trans patients believe they will recover that loss when they go off blockers. But two studies from the analysis that tracked trans patients’ bone strength while using blockers and through the first years of sex hormone treatment found that many do not fully rebound and lag behind their peers.”

““There’s going to be a price,” said Dr. Sundeep Khosla, who leads a bone research lab at the Mayo Clinic. “And the price is probably going to be some deficit in skeletal mass.””

The two studies mentioned are likely Schagen et al, (2020) (7) and Klink et al. (2015) (11). In the Klink et al. study follow-up was 5 years after puberty blocker withdrawal but most male subjects still had bone health scores below pre-treatment levels. There are no studies demonstrating a complete recovery in the majority of subjects. No studies have addressed patients who come off puberty blockers and do not receive cross-sex hormones.      

Rivers’ point that the treatment is not “safe and fully reversible” stands and Palethorpe’s point that bone health impacts are mentioned in consent forms is a red herring and does not refute this.


7. Palethorpe dismissed the WPATH President’s statement on the potential impact of puberty blockers on male sexual function as unsubstantiated by academic research.

Red herring. False.  Dr Bowers’s views were expressed in a meeting of experts  and repeated in interviews that early puberty suppressed adolescents will never orgasm. Dr Bowers has performed over 2000 vaginoplasties, an unknown but increasing number of which would have been on patients previously receiving early puberty suppression –most famously Jazz Jennings. Bowers’ views should therefore be taken seriously. That these views are not substantiated or disproven by academic research demonstrates the dereliction of duty by gender clinicians who have not investigated the issue in follow-up studies.  

Separate to Bowers’ statements, a case in the UK reports reduced sexual function “Two years on, since coming off the blockers [at age 18] Alex has still not experienced any sexual feelings”.

That most male patients will have a micropenis after early puberty suppression is substantiated by academic research. In follow-up Dutch research 70% of puberty suppressed males who later received vaginoplasty had to undergo intestinal vaginoplasty (a less common technique where a section of the colon is repurposed as a simulacrum of a vaginal canal) because there was not enough penile and scrotal skin for the more common penile inversion technique (12).    

8. It is not clear what Palethorpe is disputing in the Brik et al. (2020) and Carmichael et al. (2021).

Red herring. Several papers track continuation to cross sex hormones following on from puberty blockers and show the vast majority continue to cross sex hormones (13,14).

Palethope brings up the supposedly detailed assessments the adolescent will receive but it is not clear what his point is. Palethorpe may be suggesting that “detailed assessments” mean doctors have determined that the adolescent has a stable innate identity and will benefit from increasingly consequential medical interventions (hormones and surgery).   

However, the WPATH guidelines state that “there are no reliable means of predicting an individual [prepubescent] child’s gender evolution” (15), and there is no evidence that this differs for adolescent children. The Cass Review interim report highlights the complex aetiology of gender-related distress, including sexual abuse, LGB sexualities, and autism; and how distress can resolve and gender identity can change without medical intervention (16).

The Dutch researchers who pioneered the use of puberty blockers for gender dysphoria have also recently admitted that puberty blockers could be locking the child into dysphoria and a medical pathway: “One cannot exclude the possibility that starting [puberty-blockers] in itself makes adolescents more likely to continue medical transition” (17). The same point was made by Dr Cass in her letter of recommendations to the NHS.

In any case, Reuters reports that in their investigation into 18 gender clinics in the USA: “[n]one described anything like the months-long assessments de Vries and her colleagues adopted in their research”...Seven of the clinics said that if they don’t see any red flags and the child and parents are in agreement, they are comfortable prescribing puberty blockers or hormones based on the first visit, depending on the age of the child.”

If detailed assessments have been informally dropped in the USA it is relevant to ask if this is also the case in New Zealand and, even if they are being done, can determine if an adolescent is ‘truly trans’.   

9. Palethorpe believes that Rivers’ claim that pelvic pain from testosterone treatment encourages hysterectomy and chest binders encourage mastectomy is misleading.

Debatable. New onset pelvic pain after testosterone treatment is a common complaint in trans identified females (18–21). One study finds that the only effective treatment for this pain reported by study participants was hysterectomy (18). It is therefore reasonable to speculate in an opinion piece that testosterone treatment may be encouraging patients to later opt for hysterectomies (and sterilisation) that they would not have otherwise desired. 

A similar argument could be made regarding chest binders and chest pain. As with puberty blockers described above, early initial steps in the early medical intervention pathway appear to create additional problems, with later steps presenting as the ‘solution’.  

10. Rivers claims that there is no evidence that hormonal treatments on adolescents will lower or prevent suicide. Palethorpe counters with high reported rates of attempted suicide in non-representative surveys of transgender people. 

 Red herring. Rivers claim was “Clinicians and others may tell parents their child will commit suicide without treatment” (emphasis added). Palethorpe’s statistics are from non-representative surveys and are not relevant to the question of whether treatment lowers (or raises) suicide rates. Palethorpe misleadingly draws an equivalence between reported suicide attempts and completed suicides and reports the statistics as representative of the transgender population at large when they are from non-representative sample surveys. We do not know the suicide rate of trans identified adolescents in New Zealand pre- or post-treatment.

Overseas research is not encouraging. Suicide in trans identifying adults post-surgery intervention is elevated (22). In a recent USA study 2 adolescents out 315 participants receiving cross-sex hormones committed suicide after 2 years of followup. A suicide rate of 317 per 100,000 per year (23). 

In another study, the completed suicide rate of trans identifying adolescents on the waiting list for treatment, or receiving treatment in the UK was 13 per 100,000 per year. This is slightly lower than 15 per 100,000 per year suicide rate of 15-19 year olds in the general New Zealand population (24), and despite the UK prescribing puberty blockers at 10x less per capita than New Zealand (25). If puberty blockers did prevent suicide you would expect to see elevated suicide rates in gender-questioning adolescents where puberty blockers are much less available. 

There is no evidence that shows that, without treatment, suicide rates are raised. However clinicians in the USA often raise the spectre of suicide to bully parents into assenting to treatment: ‘would you rather have a dead daughter than a live son’. 

11. Palethorpe quibbles with the fact that the Tavistock Gender Identity Development Service (GIDS) is not yet closed when Rivers article reported this “was closed”

Red Herring. This was changed by the Herald editors. Rivers’ original article worded it as “being closed”

12. Palethorpe claims that the clinic was not closed due to unsafe practices and that the main problem at the GIDS was the lack of access to treatment. He later claims that the 10x greater usage of puberty blockers in New Zealand versus England is inline with the Cass Reviews’ recommendations implying that the NHS, following Cass’ recommendations, is going to dramatically expand prescriptions of puberty blockers. 

False. Dr Cass expresses concern at the “affirmation model” used by clinicians at GIDS and promoted by PATHA in New Zealand: 

“From the point of entry to GIDS there appears to be predominantly an affirmative, non-exploratory approach, often driven by child and parent expectations and the extent of social transition that has developed due to the delay in service provision.”(16)

Indeed, PATHA published a statement expressing “[concern] about statements in the [Cass Review] questioning an affirmative approach to gender affirming care.” It is surprising that Palethorpe was not aware of PATHA's position. One explanation is that Palethorpe is aware that the Cass Review questioned the “affirmative, non-exploratory approach” but is deliberately spreading false information.  

The Care Quality Commission (CQC) also investigated GIDS in October 2020 due to concerns relating to “clinical practice, safeguarding procedures, and assessments of capacity and consent to treatment”. The CQC rated GIDS as inadequate. Amongst findings was that some assessments were only two or three sessions and two was in breach of the NHS service specification (10).

Palethorpe’s suggestion that “Effectively, [the 10x per capita usage of blockers] demonstrate a system working in a regionally devolved manner, which is what Dr. Hilary Cass recommended in her report.” is an egregious lie. Dr Cass recommended that puberty blockers only be used in the context of a formal research program (emphasis mine).

“In light of these critically important unanswered questions, I would suggest that consideration is given to the rapid establishment of the necessary research infrastructure to prospectively enrol young people being considered for hormone treatment into a formal research programme with adequate follow up into adulthood, with a more immediate focus on the questions regarding puberty blockers. The appropriate research questions and protocols will need to be developed with input from a panel of academics, clinicians, service users and ethicists”

In practical terms, restricting blockers to formal research will scale back usage –the opposite of Palethorpe’s suggestion. 

The NHS has published a draft service specification in response to Dr Cass’ recommendation. The specification confirms that puberty blockers will only be used within a formal research protocol (emphasis mine).  

“Consistent with advice from the Cass Review highlighting the uncertainties surrounding the use of hormone treatments, NHS England is in the process of forming proposals for prospectively enrolling children and young people being considered for hormone treatment into a formal research programme with adequate follow up into adulthood, with a more immediate focus on the questions regarding GnRHa. On this basis NHS England will only commission GnRHa in the context of a formal research protocol.”

13. Rivers’ criticises the practice of treating a child as an expert and the lack of diagnosis prior to treatment. Palethorpe draws attention to assessments recommended in guidelines.

Motte and Bailey. Palethorpe leans on the ambiguity of the term “assessment”. Is an assessment performed to investigate the background factors that may have led to the child’s belief they are the opposite sex? Or is the assessment merely to ensure that comorbid issues such autism and depression are addressed concurrently with medical intervention?

If the child is treated as an ‘expert in their own gender’ then there is little space for the clinician to question the background factors as that would undermine the child’s supposed expertise. PATHA highly discourages background exploration conflating it with conversion therapy. In PATHA’s August 22 statement, referring to the Cass Review interim report, PATHA “is concerned about the use of language in the review that talks about causation of gender incongruence. Such language is often used as a preamble to conversion therapy.”

The Cass review highlights the importance of these factors, such as questioning sexual orientation, sexual or other abuse, and autism (16).

When critics like Rivers point out that comprehensive background assessments are not being done or are highly discouraged by the guidelines, and background issues are overshadowed by the clinicians acceptance and foregrounding of a self-declared trans status, Palethorpe and defenders rush in to point out that “assessments” are being done conflating the quite different intentions of the Cass- vs PATHA- recommended assessments. The paragraph quoted by Palethorpe reinforces River’s point, specifically:

“it is important to ensure that.. [mental health support] is not enforced as a requirement for accessing gender affirming care.”

PATHA could clarify the situation by publishing the number and proportion of adolescents who requested puberty blockers but were refused after assessment. If the proportion of refusals is significant it would demonstrate that PATHA associated clinicians regularly make a differential diagnosis and assessments meaningfully account for background factors, rather than simply a checkbox exercise for the medical intervention pathway.

Arguments regarding whether assessments are actually happening and can determine if the child’s identity is innate and stable are addressed in [8] above.

14. Palethorpe claims that WPATH’s guidelines have NOT removed surgery age limits.

False. Palethorpe quotes from an article published in June 2022 three months before the guidelines were issued in September. The British Medical Journal and The Economist covered the removal of age limits from the WPATH guidelines in detail. The guidelines originally had minimum age limits of 14 for cross-sex hormones, 15 for double mastectomy, and 17 for orchiectomy (removal of testicles). The age limits were removed in a haphazard process after initial publication. Surgeons in the USA have performed double mastectomies on 13 and 14 year olds who identified as boys in the USA (26). Guidelines have a quasi-legal status and the removal of age limits from the guidelines mitigates medical malpractice liabilities should these patients come to regret these procedures and take legal action against the surgeons.     


15. Palethorpe disagrees that the Relationship, Sexuality and Education (RSE) guidelines and surveys on gender identity present being transgender as an option for all primary children.

Debatable. Adolescence is a time when young people form identities to navigate the social world. Children also have concrete ideas of sex stereotypes but many resist socialisation into the sex stereotypes and face social consequences for doing so (27–29). Young lesbians in particular are vulnerable to conceptualising their resistance to female sex stereotypes and their emerging same-sex attraction as an innate male identity, leading some to pursue male imitation medical treatments (30–32). 

Palethorpe will be familiar with the concept of a “Push Poll” when a survey encourages participants to frame or align their views to the framings made by the researchers. 

We see this resistance to female stereotypes reflected in the Now We Are Eight survey of 7000 children. The findings showed that:

• 2.7% of females identified as either a boy or mostly a boy compared with 0.5% of males who identified as either a girl or mostly a girl.

• 22% of females identified as “between genders” compared with 6% of males.

• 3.4% of females were unsure about their gender compared with 1.7% of males.

A feminist analysis of the survey results would argue that the stereotypes imposed on girls are more restrictive and that status as a woman or girl is more vulnerable to violence and unwanted male attention. When significantly more girls state that they are unsure, identify as “between genders”, or identify as the opposite sex this does not represent accurate reports of these girls’ fixed, inherent non-female status, but deeper issues related to the social position of women and girls in a patriarchal society. More girls fear growing up to become women than boys fear to become men, and more girls resist the imposition of femininity. Many detransitioners reported such fears and misconceived of themselves as transgender when they encountered transgender concepts (30,33,34).

But this analysis is not present in the Now We Are Eight report, the RSE guidelines or the InsideOut Guidance used in schools. These documents conceptualise an opposite sex identification as evidence of an innate opposite-sex or non-binary self –a theory for which there is no scientific evidence. Whether or not the survey or guidance “encourages” a child to think of him or herself as having an innate opposite sex or unsexed status is debatable. In any case, there is no explanation for why many more girls than boys identify away from their own sex.     

Further, The RSE guidelines and InsideOut Guidance normalise puberty blockers as a “[variation] in puberty.” This is likely a breach of section 20 of the Medicines Act which prohibits providing information about medicines for an unapproved indication. What business is it of the Ministry of Education, the teachers who will develop lesson plans from this guidance and InsideOut coordinators to promote a medicine to children which other countries have labelled “experimental” and restricted to medical trials (35–37)? Nurses are not allowed to discuss specific medicines with patients, let alone experimental drugs, so why should teachers and untrained coordinators?

The RSE guidelines have no business promoting medical treatments to impressionable young people, particularly ones that appear to offer the medical and conceptual ‘solution’ to the anxieties of puberty and the adolescent identity crisis.    

Conclusion 

Palethorpe is clearly acting in bad faith. Half of his claims are easily shown to be false and he must be at least somewhat aware of this. Commentators have have been taken in by confidence and bluster. Rivers’ Herald article seems to have survived Palethorpes’s complaint and looks likely to survive a Media Council ruling.

To make policy and participate the body politic needs a minimal set of facts. That the ministry of health does not believe supressing an 12 year-old’s puberty for four years is a “safe and fully reversible” intervention is one of these facts. But to bring this and the other facts found in Rivers’ piece into public awareness first means getting past the tantrums, denials, and conspiracy theories of the New Zealand commentariat.

Acknowledgements

Jan Rivers contributed to this article.

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