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:
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.
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:
“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:
The direct impacts of sex hormone production is reversed, i.e sex hormone production restarts.
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]