Response to Dr Dylan Mordaunt

Dr Dylan Mordaunt is a paediatrican and an econonmist and the author of a recent article in the New Zealand Medical Journal": “The architecture of exception: a multidimensional analysis of the 2025 puberty blocker ban”. The article was covered in the NZ Herald. Around the same time I published my related letter to Ministry of Health officials and engaged with Dylan on X. Dylan wrote a response to our discussion and the MOH letter. There is a fair amount in Dylan’s response that I agree with. Unfortunately the response mischaraterises my arguments for a puberty blocker ban and there is not enough space to cover the points of agreement, which I may deal with separately. For now it is more productive to focus on the disagreement which I set out below.

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Thank you for your response. Unfortunately to cut to the chase you address an argument I do not make, and do not address arguments I actually make. Your response turns to a supposed point of our disagreement in paragraph six:

”Where I differ is the next step. My concern is the jump from “the evidence is uncertain” to “therefore initiation should be categorically restricted for this indication”.

This is not an argument I make and I do not believe treatments with uncertain evidence should be categorically restricted. To be fair, this could be said to be the argument the Minister of Health makes in deciding to prohibit GnRHa for ‘gender dysphoric minors’, and this is what your NZMJ article responds to.

My letter to MOH also does not explicitly lay out the case for ban. We did get into more of the rationale in our discussion on X but is not the best medium. For clarity, I will lay out my arguments for banning puberty blockers for children who believe they are the opposite sex here: the treatment has no benefits, induces a recognised disease state “hypogonadotropic hypogonadism” in healthy children, and is pseudo-scientific hokum. You can find similar arguments in the academic literature by psychiatrist Dr Andrew Amos here, and in a conference presentation by paediatrician Dr Dylan Wilson here.

In opposition to much of the official discourse (continued in your article), I do not believe the evidence for benefits specifically is shrouded in uncertainty. The ‘uncertainty discourse’ is partly a symptom of the dysfunction of the political establishment that cannot confront these blunter reasons for restricting the treatment without undermining legitimacy and the careers of the responsible decision-makers who allowed the practice to proliferate. Note also that we are now two years post-Cass Review final report which was in turn summarising a research published up to three years ago –making ‘uncertain evidence’ arguments based on the Cass Review somewhat out of date.

Your article makes some mistakes outlined below.

First, it assumes the treatment is legitimate. It naturally follows from this premise that legitimate treatments should be governed and regulated in the usual way you describe: “clinical standards, multidisciplinary assessment, monitoring, audit, consent and review.” With some caveats I agree that legitimate treatments with uncertain evidence should be regulated in this way.

But of course, there are also illegitimate treatments, and the medical establishment does not have an unblemished record in keeping these out of clinics. With this in mind, illegitimate treatments should just be prohibited by executive action. Yes, it is preferable that de facto prohibition would be via soft regulations like clinical practice guidelines, but where these fail and where the medical establishment gets completely off the rails there should be a place for executive action, and ideally, for the legal system to punish the responsible clinicians. There are four analogous illegitimate treatments that come to mind:

1. Female Genital Mutilation (FGM).

2. Hypothetical liposuction for anorexia sufferers.

3. Surgical limb removal for people with Body Integrity Dysphoria (people who believe they should be amputees; the older term apotemnophilia described a specific subset who had a fetish for amputation). Similar also to the surgical castration of males with a castration fetish.

4. Homeopathy (when practised to the exclusion of standard treatments)

These four never became standard treatments in developed countries. (1) is prohibited by law. (2) is unthinkable and has likely never been attempted. (3) and (4) are effectively prohibited by clinical standards. There are other treatments which have become standard which had, or may have, no benefit, especially when applied to a broad population. Your article makes a comparison to proton pump inhibitors (PPI) and ADHD diagnosis difficulties. Other examples might include: SSRI’s for teenagers, diethylstilbestrol (DES) for pregnant women, and orthopedic knee surgery. There are also other treatments which have a benefit but long-term data now shows that risk outweighs these benefits, such as in the case of surgical mesh for vaginal prolapse. We can distinguish treatments where evidence may indicate a positive benefit-risk ratio to a subset of patients but the intervention may be too broadly applied (PPI, surgical mesh, ADHD medications, SSRIs) but we should also be aware of cases like DES which was never shown to have benefits for any group of pregnant women and impacted millions.

For some of these latter ‘quasi-legitimate’ cases it could be argued that the usual clinical governance mechanisms were too slow to prevent harm and the medical fraternity was too wedded to the status quo for effective self-regulation and executive action was needed. However, except for the fact that they never became standard treatments I think the first four illegitimate treatments are closer analogies to GnRHa for adolescents and I will put the question of the listed ‘quasi-legitimate’ treatments to the side. This is because, like puberty suppression: a) 1-3 intervenes on a healthy body to induce a pathological state; b) all four have no benefit; and c) all four have belief communities that consider these interventions to be beneficial and legitimate. 1-3 offer a useful comparison and will be picked up in more detail below.

A second error is to separate out the puberty suppression from the full treatment model and fail to consider its exceptional nature. So called “Gender Affirming Care”, ‘GAC’ induces recognised disease states in bodies with no verifiable underlying pathology. The psychosocial intervention aspect is to reinforce the child’s false belief in themself as a member of the opposite sex. These aspects are certainly atypical and warrant more thorough discussion.

The third error is that the article treats the Minister’s statements and the Cass Review at face value. However, it is better to treat these statements as political compromises. We are in a situation analogous to the Emperor’s New Clothes. The Minister citing the ‘uncertainty of evidence’ is like a courtier informing the Emperor that ‘his clothes are certainly very fine but it would be wise to acquire a more substantive cloak lest his Majesty catch a chill’. The ‘uncertain evidence’ discourse should be interpreted with a mind to what politicians and public servants feel they can say in the current political environment. The ‘GAC’ / ‘transgender rights’ belief community includes media executives, public servants, medical professionals, politicians, the NGO sector and so on. Perhaps a larger number in this professional-media class are not dyed-in-the-wool adherents, will have doubts, but will also publicly affirm its tenets (e.g. ‘declare their pronouns’ in their email signature) because they judge this to be more advantageous to their careers. There is little political incentive in New Zealand to confront the ‘GAC’ belief community directly.

There are other issues such as the NZMJ article failing to mention the Commission on Human Medicine’s report finding that puberty suppression in the UK represented an ‘unacceptable safety risk’; the omision of discussion that the UK trial faces ethical and legal challenges, which if were to be found to be insurmountable, would also obviously apply to use outside a trial such as in NZ; and while you cite our article, Paul et al. (2024), the implications of the treatment rate disparity between NZ and the UK is not drawn out. Or for that matter, Finland and Denmark where <10 adolescents per year are treated with GnRHa and hormones. However, the current discussion is not a review of your NZMJ article but an explanation of rationale for a ban, so I will move on to the illegitimacy of puberty suppression.

Supposed Benefits

Proponents have promoted the mental health benefits of puberty suppression.
There are five things to say about this benefit:

1. Some children, perhaps as much as a third, appear to decline in mental health and it is not possible to predict which ones.

2. The effect sizes for cohorts that report mean benefit are tiny, below comparable placebo, and clinically insignificant.

3. Clinician-researchers have spent 15 years looking for a mental health benefit with initial modest findings unreplicated. Many are now abandoning this rationale and moving on ‘embodiment goals’. If a pharmaceutical company claimed that a drug had a specific benefit, as ‘GAC’ clinicians have done in regards to mental health, but then abandoned that claim, that would be consumer fraud, and prohibited under the Medicines Act.

4. That GnRHa could benefit a child depends on the child having a relatively fixed ‘gender identity’ (whether already settled or, with the usage of GnRHa as a ‘pause to decide’ framing, awaiting potential discovery) that the clinician’s role is to recognise and affirm. The ‘gender identity’ proposition conflicts with the accepted developmental psychology you would have touched on in paediatric training (Erikson, Piaget, Bandura etc). Identity formation in adolescence is expected to be unsettled with premature commitment (‘foreclosure’) the suboptimal outcome. According to these authorities, identity is psycho-social and developmental, arrived at through cognitive maturation and social learning. But gender identity theory inverts this. Identity is taken to be innate and authoritative on the child’s own report while simultaneously being ‘fluid’ and varying in a ‘gender journey’. Proponents of ‘gender identity’ classify the clinical exploration of how the child arrived at an opposite sex identity (i.e. routine differential diagnosis and exploratory psychotherapy) as ‘conversion therapy’, and assert that such alternative modalities are unlawful. This is in opposition to the medico-ethical practices of differential diagnosis and fully informed consent, which require the clinician to explore and inform the patient of alternatives. This makes gender identity theory and the treatment model dangerous, pseudo-scientific hokum.

5. GnRHa also has product warnings for depression (in rare cases suicide attempts), and is not expected to enhance mental health for other patient groups –in fact the reverse.

Given the above, at this point it is safe to say that there are no mental health benefits. Like other sex trait modification interventions, reported benefits from some cohorts are likely from the concurrent psychosocial support, and not the actual medical intervention. Without a benefit clinicians’ ‘weighing risk and benefit’ is a pretense.

You stated on X the benefits are “complex” but if you’re going to assume the treatment is legitimate then the onus is on you to articulate how a treatment that induces physiological abnormalities will benefit patients. Your response gives a very light touch to Ootohoek et al. who not only call for a “clearer discussion of the aims of gender-affirming medical treatment” as you put it, but also highlight an ethical framework where “[so-called] healthcare is provided and justified on the basis of personal desire and autonomy”; and in the context of discussing hormones for adolescents aprovingly quote Chu who states that “no amount of pain, anticipated or continuing, justifies its withholding.” It is inadequate to stay at the high level and call for a discussion on a “better outcome definition”. I ask that you get your hands dirty and defend the public health system hormonally (or surgically) modifying the bodies of adolescents who desire their bodies imitate the opposite sex even in the face of no (or detrimental) impacts on mental health.

This rationale only work from within a community that believes in ‘gender identity’ and ‘transgender children’, and brings us to the first analogy: FGM.

FGM

FGM is practised in a number of cultures but in developed countries is most often associated with the North African diaspora. Within these cultures FGM is endorsed by loving parents who believe FGM benefits the girl via improving marriageability and that this benefit outweighs health and life course risks (namely permanently impaired sexual function as well as other complications). FGM belief communities in developed countries can include medical professionals, some of whom have been caught practising or abetting FGM and criminally prosecuted.

Compared to FGM, ‘GAC’ is administered in stages, and any harms in the early stages are less immediate. Yet considered in full, the long-term impacts are potentially more severe and wide-ranging than FGM. ‘GAC’ surgical interventions obviously remove more healthy tissue than FGM, and can be complex surgeries. Puberty suppression of males begun in early puberty can arrest penile growth (and sexual development) resulting in “penoscrotal hypoplasia” with uncertain reversibility (CHM), a serious harm in its own right. There are additional risks of impaired bone density and cognitive deficits. When blockers are followed by cross-sex hormones, the NSW health authority suggests this may breach laws prohibiting treatments that cause permanent infertility in children. Independently, estrogen treatment in males is associated with increased stroke risk, while testosterone use in females is associated with high rates of pelvic pain and pelvic floor dysfunction (94% in one study). None of these risks are particularly surprising given that treatments induce physiological abnormalities. For adolescents, this occurs during a critical development period. I submit these are less ‘uncertain risks’ and more the expected outcomes of induced abnormalities (Ray Yuan Zhang, one of the athors of the HHS review, makes a similar point here). In summary, when viewed dispassionately, the harms of ‘GAC’ are arguably greater than that of FGM.

The ‘GAC’ belief community also believe they are acting in the best interests of the child. The treatments are also usually (but not always!) endorsed by loving parents wanting the best for their child. They believe that medically modifying a body to imitate the opposite sex will help the person live more ‘authentically’. But this rationale only makes sense with the GAC belief system. To outsiders, they are pursuing a foolish enterprise. Attempting to deceive oneself and others via medical interventions to imitate the opposite sex could never be a solid basis for wellbeing. The rationales of both of these belief communities are equally peverse.

Anorexia, Body Integrity Disorder (BID), and Castration Fetishists

Other belief communities wish to modify their bodies outside healthy norms to pursue an overvalued belief and some have recruited clinicians to their cause. Adolescents with anorexia can adopt a ‘pro-ana’ identity and connect on online discussion forums where participants frame their unhealthy behaviours as a lifestyle choice. People with BID or castration fetish similarly form communities in which an unhealthy bodily state is framed as the alignment of body to identity. In each case the belief community holds that the intervention —sustained underweight via undereating, limb amputation, surgical castration — resolves distress by bringing the body into line with the patient’s true self.

Mainstream medicine has declined to provide these interventions. The Scottish surgeon Robert Smith did carry out two limb amputations for BID at Falkirk Royal Infirmary in the 1990s before the hospital halted the practice. Otherwise, medically intervening on these individuals to respect their ‘autonomy’ is not considered legitimate, and no one serious would complain of a politician stepping in to ban them if the medical community failed to prohibit such practices via self-regulation.

This is also where the PPI comparison breaks down. PPIs do induce a (relatively mild) state outside the healthy norm, but they do so to correct an underlying, verifiable pathology (acid-mediated mucosal damage). You may reasonably ask whether psychiatric medications such as SSRIs occupy the same ground as puberty suppression, since they too treat distress without correcting any verifiable somatic pathology. Putting to the side that a SSRI (prozac) also has no benefit superior to placebo for children, psychiatric drugs target the distress itself, and are evaluated against endpoints independent of the patient’s beliefs. They do not act on a healthy body to bring it into conformity with a false belief. With pro-ana, BID, castration fetish, and puberty suppression for gender-distressed adolescents, the intervention alters a healthy body to match the patient’s overvalued belief about it. The intervention has no demonstrated benefit beyond the patient’s self-reported (short-term) satisfaction with the alteration. There is no functional, biochemical, or independent endpoint that improves. The Minister should be entitled to make the normative judgement that this is not something the health sector should engage with.

The ‘GAC’ belief community differs from pro-ana, BID, FGM, and the ‘eunuch identified’ only in that it has obtained the institutional adoption the others have not. Exploring how it gained that adoption is beyond the scope here. But the inconsistency is worth noting: surgical castration of the ‘eunuch identified’ is, technically, already endorsed by Health NZ. Chapter 9 of the WPATH SOC8 guidelines provides for castration of the ‘eunuch identified’ and observes that they ‘may be aware of their identity in childhood or adolescence’ (p. 89). Health NZ has mandated alignment with WPATH SOC8 and contracted PATHA, WPATH’s New Zealand affiliate, to write the New Zealand guidelines. Unless Health NZ is now picking and choosing which parts of SOC8 are legitimate, presumably our public health system should be assessing the ‘eunuch identified’ and spending public resources on surgical castration as it does for the trans-identified. But of course they are not going to formally endorse it. The castration fetish community may have been able to convince WPATH to endorse their treatment preferences, but they do not have the same political sway as the trans-identified has with Health NZ.

Summary

The key question is what do when self-regulation of the medical community fails? We put our lives and wellbeing in the hands of medical professionals and are perhaps averse to seeing them in a less flattering light. But medical professionals and their governance bodies have the same venal pressures as any other institution.

Puberty suppression shares features with illegitimate treatments. There is no underlying somatic pathology. There is no mental health benefit. The intervention induces a recognised disease state in a healthy body to modify it to conform to the false beliefs of the patient. Treatment rationales rest on a theory of identity that conflicts with mainstream developmental psychology, and the framework forecloses differential diagnosis. The ‘GAC’ belief community differs from the other illegitimate treatments only in that it has obtained the institutional adoption the others have not. The executive should ban such treatments. Ideally the executive could be direct and honest about this and why this is necessary. For now, in New Zealand, we have to live with the pretense that this is all because of ‘uncertain evidence’.