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Post-Tavistock reform and disorder; a Finnish honour; so trans-affirming in Germany; a criminal probe at Florence's gender clinic; and evidence-based medicine gets to say 'told you so'

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GCN in brief

British clinical psychologist Anna Hutchinson, a former senior clinician at the Tavistock gender clinic, has called for a return to “ordinary best practice” to help minors who present with gender distress, the BMJ has reported. At the First Do No Harm conference in London on March 23, Dr Hutchinson recommended non-invasive methods such as counselling, saying the practices at the Tavistock had been “extraordinary”.

“There is no precedent for putting children on a serious medical pathway of puberty blocking drugs, cross-sex hormones, and sex-change surgery following a mental health diagnosis,” she said. “Clinicians know how best to help distressed children that puts them at the heart of interventions and protects them from possible harms.” In 2018, she had said she felt the Tavistock was “routinely offering an extreme medical intervention as the first-line treatment to hundreds of distressed young people who may or may not turn out to be ‘trans’.”

In its report on the March 23 conference organised by the Clinical Advisory Network on Sex and Gender (CAN-SG), the BMJ also quoted CAN-SG co-chair and London psychiatrist Stella Kingett as saying that, “Doctors face a great deal of uncertainty at the moment as the strongly affirmative approach taken by the Tavistock is now being questioned. They need evidence-based guidelines from royal colleges that are not cowed by external or internal activists.”

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Recognition

Riittakerttu Kaltiala, the Finnish psychiatrist and researcher who helped initiate Europe’s shift to caution on the treatment of gender-distressed minors, has been awarded her country’s most prestigious medical honour. In her acceptance speech, she highlighted the challenge for adolescents to develop a stable identity. Professor Kaltiala, who is chief psychiatrist in the department of adolescent psychiatry at Tampere University Hospital, linked the increase in poor mental health to lack of support for adolescent development, remarking that, “The slow evolution towards an authentic self is giving way to a lightning-fast self-presentation on ever-vigilant social media platforms.”

Video: Professor Kaltiala presents at the 2023 New York conference of the Society for Evidence-based Medicine

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Post-Tavistock disorder

In England, where the Tavistock clinic is to close on March 31, the focus has shifted to the welfare of older adolescents aged 16-25 whose brains are still maturing. That is the age group targeted by a new private service, the Gender Plus Hormone Clinic, run by an ex-Tavistock psychologist. On March 24, Tavistock whistleblower and psychotherapist Sue Evans foreshadowed a High Court challenge to the decision by the Care Quality Commission (CQC) to license the Gender Plus clinic, which offers cross-sex hormones from the age of 16. This intervention lacks long-term evidence, according to the case brought by Ms Evans and the mother of a gender-distressed 15-year-old. Their solicitor, Paul Conrathe from SinclairsLaw, told The Times that, “The decision of the CQC to license the first paediatric hormone clinic is a leap in the dark.” The CQC had given the Tavistock its lowest rating of “inadequate.”

In a separate legal challenge, Anna Castle, the mother of a teenager with ADHD, argues that adult gender care should involve safeguards such as sustained psychological therapy, especially for patients with neurodiverse conditions. Mr Conrathe, who also acts in this case, said England’s National Health Service (NHS) had “decided to refer 17-year-olds seeking treatment for gender dysphoria to the adult clinics where there is no requirement for psychological treatment. Lifelong irreversible hormonal treatment can then be given after only two appointments.”

On March 21, the NHS announced cross-sex hormones would be routine treatment for gender dysphoria or incongruence from “around their 16th birthday”. This seemed at odds with the cautious NHS decision on puberty blockers, according to journalist Hannah Barnes, who documented the shortcomings of the Tavistock clinic. In The New Statesman, she said it was surprising that the March 21 announcement made no reference to the 2020 systematic review noting “the largely unknown long-term safety profile” for under-18 hormone treatment. The NHS statement did leave open the possibility of a policy change in the light of the final report of paediatrican Dr Hilary Cass, who has led an independent review of dysphoria care; her report is expected next month.

Video: Sue Evans, Anna Castle and Paul Conrathe outline the two new judicial review cases

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Trans-affirmative autobahn

Germany’s new treatment guideline for gender dysphoria or incongruence in minors will not follow the restrictions applied by new, more cautious treatment policies in Finland, Sweden and England, according to the medical magazine, Deutsches Ärzteblatt. After several years’ work, the near-completed guideline was presented for the first time last week, with 27 specialist societies and two transgender advocacy groups having reached agreement on the question of hormone suppression. There was strong consensus that the distress of dysphoria—not mere incongruence—should be a prerequisite for prescription of puberty blockers.

Although this intervention was said to be “generally reversible”, the guideline reportedly acknowledges the possibility that psychosexual development might be affected by delaying the brain maturation processes of puberty. No minimum age for pubertal suppression is to be applied. One of the guideline authors, Dagmar Pauli of the Psychiatric University Hospital Zurich, told Deutsches Ärzteblatt that “it is a dilemma that pubertal changes often occur when adolescents are not yet fully capable of judgement and making decisions about medical measures.”

The “decidedly trans-affirmative” direction of the guideline had been criticised by the Munich-based child and adolescent psychiatrist Alexander Korte, who has treated adolescents with gender dysphoria since 2004. The confidence of the guideline is also at odds with the findings of a recent systematic review of the evidence base undertaken by child and adolescent psychiatrist Florian Zepf of Jena University Hospital and colleagues.

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Police matter

A criminal investigation has been opened following an audit of the gender clinic at Florence’s Careggi hospital, according to the newspaper Corriere della Sera. The puberty blocker drug triptorelin had been authorised for off-label use in 2019 by the Italian Medicines Agency (Aifa), subject to psychological and psychotherapeutic support and diagnosis by a multidisciplinary team involving a child neuropsychiatrist. However, the newspaper said two Careggi gender doctors had declared psychotherapy unnecessary and stated that the child neuropsychiatrist visited only once a month. The audit of the clinic was ordered by Health Minister Orazio Schillaci, but the criminal investigation was opened by the Florence Public Prosecutor’s Office.

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Rear window

England’s abandonment of puberty blockers as routine treatment comes almost exactly five years after a review in the British Medical Journal concluded that hormonal interventions for minors with gender dysphoria “remain largely experimental” and should be restricted to research.

That literature review was published on 25 February 2019 in the BMJ Evidence-Based Medicine (BMJ EBM) journal by Oxford University’s professor of evidence-based medicine Carl Heneghan and his colleague Tom Jefferson, who is a former researcher at the Nordic Cochrane Centre.

On 8 April 2019, Professor Heneghan was quoted in reportage by The Times of concerns raised by whistleblower staff from the Tavistock clinic; one clinician had said “very vulnerable children” were being subjected to “experimental treatment” with puberty blockers.

Professor Heneghan was quoted as saying: “Given paucity of evidence, the off-label use of drugs [for outcomes not covered by the medicine’s licence] in gender dysphoria treatment largely means an unregulated live experiment on children.”

This material was drawn from an opinion article by Professor Heneghan published the same day by The Times, in which he said—

“The available evidence comes from small studies, is retrospective rather than prospective, and has lost considerable numbers of children in the follow-up. Studies also lack control groups (making it difficult to tell anything about the intended effects), there are no randomised trials and the presence of subjective outcomes along with the lack of blinding mean all together the current evidence does not support informed decision-making. The dearth of evidence in gender dysphoria doesn’t surprise me. What does surprise me is that we have devolved responsibility for making life-changing decisions to one clinic [the Tavistock], to a few doctors, with no national guidelines in place. And that we have accepted that individuals facing distressing life-changing situations are ill-informed.”

And now, on their Substack newsletter Trust the Evidence (TTE), Professor Heneghan and Dr Jefferson have recorded the fact that England’s NHS has belatedly reached the same conclusion.

“In the intervening years, we’ve been labelled as transphobes, subject to three different complaints at the University of Newcastle, where Tom was a visiting professor, Oxford and the BMJ, where we posted the original review,” they said.

“All of these were dismissed—it’s hard to argue that reviewing the evidence should be subject to complaints. But it did have a chilling effect to shut down our BMJ EBM posts.” (The BMJ denies this claim and cites contributions to the journal by both authors since the time of the complaint arising from the 2019 review.)

“At TTE, we do not have any vested interest in the outcome of treatments when we review the evidence,” Professor Heneghan and Dr Jefferson said in their March 18 post.

“Yet, consistently, we have found that an evidence-based approach has proved controversial. People tend to hold strong beliefs and convictions about various treatments, which is precisely why an impartial, evidence-based approach is crucial.

“For all those following an evidence-based approach, it’s essential to be ready for the onslaught of complaints, insinuations, and abuse that comes with the territory. However, keeping to an evidence-based approach is critical to informing decisions—in the end, the evidence will win out—and the question is how many are harmed before we get there.”