Biased brains

Plus: South Africa’s guideline wars; AGP & the UK trial; the German ploy in Norway; French lessons; puberty blocker politics in Oz; Canada conscripts doctors; DIY hormones; Dutch queering of consent

Photo by The New York Public Library on Unsplash

GCN global briefs

Unreliable intellects

International | Dr Richard Santen, a former president of the Endocrine Society, attributes the controversy over paediatric medical transition to intellectual conflicts of interest, a reference to a guideline author whose work may be “jeopardised or enhanced” by the guideline. In the crucial guidelines for paediatric medical transition, Dr Santen’s new journal article states that 9/10 authors of the Endocrine Society document had an intellectual conflict of interest, with the same conflict affecting 117/121 of the authors of the standards issued by the World Professional Association for Transgender Health (WPATH).

The Cass Review, he says, used an assurance committee of “individuals who were not involved in the care of gender dysphoric adolescents and, on this basis, apparently lacked intellectual conflicts of interest”. Dr Santen contrasts Dr Cass’s cautious treatment recommendations with the pro-medicalisation stance of WPATH and the Endocrine Society. He attributes this difference to the fact that the Endocrine Society and WPATH committees “had members with intellectual conflicts of interest and the Cass Review did not. My analysis also suggests that the [WPATH and Endocrine Society committees] leaned more on crafting recommendations based on expert opinion and the Cass Review on data from systematic evidence reviews.”

Take it down

South Africa | A group of professionals concerned about the medicalisation of minors took the novel step of seeking the retraction of a “gender-affirming” guideline published in 2021 by the Southern African Journal of HIV Medicine. The guideline promotes puberty blockers, claiming that, “The prospect of puberty and developing secondary sexual characteristics in conflict with experienced gender identity is often daunting and even traumatic for a [trans] adolescent. The [mental health professional] should work with the adolescent and their caregiver(s) and, if appropriate, facilitate access to puberty pausing treatment.” This “condensed” form of the guideline frames the medical treatment of minors with blockers, hormones and surgery as a constitutional right to health.

In a letter to the journal’s editor-in-chief last year, members of the professional group First Do No Harm Southern Africa (FDNHSA) cited multiple reasons for retraction of the guideline-article, including a misleading suggestion of national endorsement for the document; lack of a “gold-standard” systematic review of the evidence base; recommendations influenced by the “discredited” WPATH; editorial and peer review failures; and unethical recommendations where, for example, irreversible interventions on minors would be allowed from age 12 and over without legally requiring parental consent (the condensed version of the guideline differs here from the “expanded” version). The journal dismissed the request for retraction, leading FDNHSA to pursue the issue with the publisher. GCN has sought comment from the journal.

In March this year, the publisher instructed the journal’s editorial board to investigate the retraction request. According to FDNHSA, two authors of the guideline-article in question are members of the editorial board and sat on the committee to decide the retraction request. That request was turned down. However, the journal subsequently ran a disclaimer headlined “Editorial Expression of Concern for the Guideline ‘Southern African HIV Clinicians Society gender-affirming healthcare guideline for South Africa’”. The disclaimer acknowledged that the 2021 guideline-article “did not undergo the journal’s standard journal-led external peer-review process”.

In June, the journal also published a letter from retired paediatrician Dr Mark Patrick, who pointed out that the gender guideline was outside the scope of HIV medicine. “It is concerning that the Southern African HIV Clinicians Society and its journal, in publishing this guideline, recommend interventions that cause sterilisation and create lifelong medical dependency,” Dr Patrick said.

In August, the journal returned to the domain of paediatric gender medicine, publishing a “rapid review of gender-affirming healthcare for children and adolescents”. When that review first appeared as a preprint, FDNHSA wrote again to the journal, saying the review was “a record of a cherry-picking exercise in finding articles and using them to support the preconceived ideas and beliefs of the review’s ‘queer- and trans-led’ authors”. It did not amount to a review of the 2021 guideline, FDNHSA said.

The rapid review declared some funding from the South African trans rights group Gender DynamiX. This group, FDNHSA said, had received US$500,000 from the Arcus Foundation, an LGBTQ lobby group which had “explicitly prioritised” South Africa in its grants program. Like the 2021 guideline, the 2026 review was marked by apparent bias and conflicts of interest, according to FDNHSA. Some authors appeared on both documents, with the appearance of reviewers rating their own work.

The rapid review makes strong claims—for example, that “Adolescents who access puberty suppression and/or GAHT [cross-sex hormones] generally show reductions in depressive symptoms and suicidality, alongside improved appearance congruence and functioning, compared with their own baseline and with peers who want but cannot access treatment.” There is no firm basis for the implied causation. Several credible systematic reviews, run in a range of jurisdictions internationally, have found the evidence for hormonal treatment of gender-distressed minors to be very weak and uncertain.

Who’s in, who’s out?

United Kingdom | The Medicines and Healthcare products Regulatory Agency (MHRA), which approved the PATHWAYS puberty blocker trial, has confirmed that adolescents with the atypical sexual attraction known as autogynephilia (AGP) should not be eligible for the trial. Psychologist Dr Ray Blanchard describes AGP as a condition in which a heterosexual male is sexually aroused by the image of himself as female; some AGP males will seek medicalised gender transition. “From a parent’s perspective, autogynephilic gender dysphoria (which occurs only in natal males) often seems to come out of the blue,” Dr Blanchard and fellow psychologist J Michael Bailey have argued.

Unless parents and adolescents in the trial are made aware of AGP, there cannot be informed consent, according to “Orlando”, a pseudonymous man who experienced AGP as a minor. Orlando believes that patients in the puberty blocker trial could be harmed if adolescents with AGP are not excluded from eligibility.

Orlando, drawing on his own experience, believes the correct response to AGP is to give adolescents information about the condition, not to put them on puberty blockers with known harms.

The two agencies responsible for ensuring a safe and ethical trial of puberty blockers—the MHRA and the Health Research Authority (HRA)—appear to have contradictory positions on the AGP issue. When Orlando outlined his concerns in September 2025, the HRA said AGP was not relevant to the trial, in which eligibility focuses on the presence of gender incongruence.

In August this year, Orlando received a response from the MHRA, eight months after he put his case to that authority. The MHRA told him that it would ask those running the trial—led by Professor Emily Simonoff of King’s College London (KCL)—to notify the authority if any of the adolescents in the trial “are found to have autogynephilia post-enrolment … so this could be further followed up, as it is clear that they should not be included in the clinical trial from the explanation given by the PATHWAYS team and the trial eligibility criteria”. In the MHRA’s opinion, a potential participant in the trial who had autogynephilia without gender incongruence would be detected and not included in the trial.

Arguing that a diagnosis of gender incongruence does not exclude AGP, Orlando has sought a further response from the HRA. He said the question was whether KCL would update its trial protocol in light of the MHRA concession; also, which entity would be liable if adolescents with AGP do suffer harm in the trial?

“If the sponsor [KCL] says a boy with autogynephilia should not have been enrolled, the parent form should say so,” Orlando said. “The information sheet, as last published, does not. Parents cannot give informed consent if they are never told about something the medicines regulator treats as a reason their son should not be in the study.”

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See you in court: Christina Woods and Courtney Schneider from the ‘Those Who Speak’ team talk detrans litigation with Lynn Chadwick and Kathleen Dooley of Themis Resource Fund.

Why the Germans?

Norway | The Norwegian Directorate of Health has been asked to examine the gender treatment guidelines of Germany, Switzerland and Austria. The Minister of Health and Care Services, Jan Christian Vestre, cited a specific request from two transgender advocacy groups that German-language jurisdictions be a possible model for Norway. In 2023, Norway’s independent healthcare investigator Ukom described the hormonal treatment of minors as experimental and recommended that the country’s 2020 gender-affirming guidelines be revised in the light of a “gold-standard” systematic review of the evidence. That revision is yet to happen.

The redirected focus on Germany, Switzerland and Austria in fact relates to a single, German-language guideline issued amid strong criticism in March 2025. Unlike evidence-based guidance in England, Finland and Sweden, the German-language project failed to carry out a systematic review of the evidence and ignored the European shift to a more cautious treatment policy.

The group Gender Identity Challenge (GENID) Norway, a critic of the gender-affirming model, said the decision to exclude the guidelines from Finland and Sweden—jurisdictions similar to Norway’s—was “particularly striking”. In an opinion article for the liberal-conservative newspaper Minerva, the GENID board called on Minister Vestre to explain the choice to examine the German-language guideline and not others, and to account for the failure to implement a revision of the 2020 guideline starting with the foundation of a systematic review.

Eminence-based liability

United States | The American Academy of Pediatrics, WPATH and the Endocrine Society have failed in their attempt to get a case against them thrown out of court. The allegations brought by Florida’s Attorney General James Uthmeier include false and misleading claims that puberty blockers are fully reversible, that credible evidence shows a reduction in suicidality in transitioned minors, and that the guidelines of these three organisations are evidence-based. In their defence, these organisations argue that their guidelines are speech protected by the Constitution’s free-expression guarantee.

In a separate legal action brought by the Federal Trade Commission, WPATH frames its standards as constitutionally protected opinions expressed in the contested debate over paediatric medical transition.

Writing for City Journal, commentator Leor Sapir says: “WPATH’s new framing, that [its standard of care document] is merely one perspective in a debate marked by ‘scientific and medical uncertainty’, implies that it has always seen debate over the medical pathway as legitimate and has been willing to engage with, or at least tolerate, critics. Nothing could be further from the truth.

“WPATH has long maintained that puberty blockers, cross-sex hormones, and surgeries constitute ‘medically necessary’ and even ‘life-saving’ care for some (and potentially ‘most’) kids with gender dysphoria. For years, WPATH and its allies went to great lengths to tarnish the reputation of critics—external and internal—while aggressively maintaining that the ‘science is settled’ on the necessity of medical interventions.”

In WPATH’s own videos, gender clinicians openly discuss the misuse of non-gender diagnostic codes, journalist Benjamin Ryan reports. Critics of gender medicine, including the Trump Administration and the watchdog group Do No Harm, allege that gender medicine makes fraudulent use of incorrect billing codes in order to secure health insurance reimbursement and conceal the nature of medical interventions.

Mr Ryan cites the response of psychiatrist Dr Teddy Goetz when asked how to use a non-pathological diagnosis to justify medical transition. In the video, Dr Goetz says, “You could switch your billing code to ‘unspecified endocrine disorder’, for example, saying that their body produces less testosterone than it should for them to feel their best. So, there are different ways that you can work around that. And thinking about moving towards euphoria and away from dysphoria.”

Do No Harm has urged the Department of Health and Human Services to look into potential fraud by Planned Parenthood in its diagnostic coding for hormones and insurance billing. “Our investigation suggests Planned Parenthood and its regional affiliates may be perpetrating a nationwide miscoding scheme to conceal services for sex-rejecting procedures and to facilitate improper insurance reimbursements for cross-sex hormones,” says Dr Kurt Miceli, chief medical officer at Do No Harm.

Go to jail

Colombia | A Mexican YouTuber, Samuel Adrián, whose documentary made allegations about the gender medicalisation of minors in Colombia, was arrested on arrival earlier this month at Bogotá’s El Dorado Airport, The Washington Stand reports. His documentary, “Colombia: Factory of Trans Children”, caused a public furore and was followed by the closure of the gender paediatric clinic at the elite Valle del Lili Foundation hospital in Cali. In May, a court in that city imposed a 10-day arrest and a fine on Mr Adrián for his refusal to comply with a ruling that he remove specific clips from the documentary and related videos featuring Dr Mario Angulo Mosquera, the former director of the gender clinic run by the Valle del Lili Foundation hospital. Mr Adrián is expected to be released on September 24.

Errors to dodge

France | The Little Mermaid Observatory watchdog group has issued a new guide for parents and professionals responding to a teenager’s trans identification. In an introductory note for parents, the guide says: “Most families discover this phenomenon when it affects them directly, without any prior preparation, at a time when it is necessary to act early and without error. Time is of the essence, and two symmetrical errors precipitate the adolescent into medical transition. The first mistake, which appears well-meaning: immediate validation, social transition at home, and referral to an affirming healthcare provider—an approach which, in reality, locks in the clinical progression to such an extent that almost all children managed in this way end up receiving hormones and surgery, without further assessment.

“The second, symmetrical error: outright rejection, threats, ideological arguments and an emotional breakdown—an approach that drives the adolescent to seek refuge in the activist community and to wait until they reach the age of majority to undertake medical transition on their own, against their parents’ wishes.” The 35-page French-language guide can be downloaded free of charge.

Blockers blocked

Australia | A newly subsidised status for the drug Triptorelin 3.75mg will not include its use as a puberty blocker for minors with gender dysphoria, according to the federal Department of Health. There has been confusion about this. On September 17, federal Health Minister Mark Butler announced that the drug would be available from October 1 on the Pharmaceutical Benefits Scheme (PBS) for women’s health conditions including breast cancer and endometriosis. Triptorelin is a substitute for another hormone suppression drug, Zoladex 3.6mg, which is being withdrawn from the Australian market by its manufacturer.

Following expert advice from the Pharmaceutical Benefits Advisory Committee (PBAC), Triptorelin will be listed on the PBS as unrestricted, which usually means a drug would be available in subsidised form for any health condition. However, a Department of Health spokesperson told GCN: “The listing is being implemented with an administrative note that says, ‘The listing of this medicine is not for the use in gender dysphoria in minors’.”

As recently as the morning of September 21, members of gender medicine lobby the Australian Professional Association for Trans Health (AusPATH) were told that gender dysphoria was to be included. This would price a PBS prescription for Triptorelin at no more than $25 per subsidised script for a month’s supply. The cost for a private, non-subsidised prescription is $264-$271 a month. (Gender clinics in state children’s hospitals outside Queensland typically pay for puberty blockers.)

On Monday morning, AusPATH chief executive Eloise Brook emailed members: “For trans and gender-diverse people, the significance of the word ‘unrestricted’ is important. Unlike a restricted PBS medicine, an unrestricted benefit is not limited by the PBS to particular clinical indications [or diagnoses].”

Ms Brook, a transwoman, cited Mr Butler’s September 17 media release, although it focused on women’s health and made no mention of gender dysphoria. “AusPATH has also confirmed the change directly with [the drug company] Ipsen, the Australian sponsor of [Triptorelin 3.75mg],” she said. (GCN has put questions to Ipsen.)

In October, the National Health and Medical Research Council (NHMRC) is due to issue interim advice on the use of puberty blockers for gender distress. A range of jurisdictions internationally have restricted or banned the use of hormone suppression drugs for this purpose, citing insufficient evidence about their safety and long-term effects.

On the afternoon of September 21, Ms Brook updated AusPATH members to say that in fact gender dysphoria was not to be included in the PBS unrestricted listing. She said neither AusPATH nor Ipsen had been given prior warning of this exclusion. She said she learned of the development from a journalist for The Guardian Australia, who had “contacted the Minister’s office directly”.

She said the Minister’s office was reportedly “concerned that the inclusion of trans young people in the listing would have come ahead of the NHMRC’s interim guidelines [on puberty blockers] and brought criticism”. The chief of staff [for Minister Butler], she said, “was explicit that the early posting [to the effect that gender dysphoria would be included] that came out of AusPATH was not a factor in their decisions. They were already prepared for backlash.”

On August 18, a news report in The Guardian claimed that the PBAC experts had recommended that gender dysphoria be included in the unrestricted listing. In fact, the PBAC advice from July cited “a number of women’s health conditions”, and made no reference to gender dysphoria. The Guardian is yet to correct its coverage. GCN has sought comment from the Minister’s office and The Guardian.

Coercive medicine

Canada | A human rights tribunal in British Columbia has ordered a physician, Dr Henry Ajaero, to pay $28,100 for discrimination because he declined to inject a 14-year-old with a puberty blocker. He had cited conflict with his religious beliefs and said puberty suppression was beyond his scope of practice. The ruling is part of a trend whereby “prevailing progressive social consensus” will trump Canada’s constitutional guarantee of freedom of religion, according to retired lawyer Peter Sim. Worse, he says, the tribunal in effect substituted its own opinion for Dr Ajaero’s, failing to show the customary deference to medical judgment.

DIY hormones

United States | The website diyhrt.wiki is one among various online portals potentially allowing minors to access hormones without prescription or safeguards, Do No Harm reports. The website’s “Transmasc Guide” says: “Ideally, you would be on T [testosterone] through legal means. However, you may not have the privilege, so this guide may be of better use for you.” Entry to the website simply requires visitors to click a button stating, “I am 18 or older”. The page on Injection Supplies offers sources of syringes and needles in the US, UK, Australia, Canada, Sweden and France.

Beyond consent

Netherlands | Researchers including Dr Annelou de Vries of Amsterdam clinic fame have devised a novel response to international concern that minors may lack the capacity to consent to paediatric medical transition. In a new paper, the Dutch authors suggest the problem lies with the medico-legal concept of informed consent. Rather than expecting consent before medical intervention, they say, the reality is that adolescents will not get the requisite understanding until afterwards.

“While [the teenagers who were interviewed] describe receiving information about medical treatment and its possible risks during clinical consultations, their (embodied) understanding of gender-affirming treatment was mostly established through medical transition itself. In other words, the very effect and meaning of treatment often became intelligible only through lived experience.”

Also, teenagers learn how to game informed consent. “As clinicians seek clinical accounts that can be interpreted as authentic and coherent, adolescents learn which narratives of gender dysphoria or incongruence are recognized within clinical practice and (explicitly or implicitly) adapt to these in order to access care.”

Reasons not to transition

Australia | Within nine months, the model of care at the Perth Children’s Hospital gender clinic underwent a striking change, according to documents obtained under Freedom of Information law. In December 2020, families considering social transition of a child before puberty were to be told “that current evidence suggests that of children who express significant gender dysphoria in childhood, more than half identify with the birth-assigned sex in adolescence and adulthood”.

The model noted “the importance of not allowing a child to be pushed into social transition by adults who may be uncomfortable with gender nonconforming behaviour”. The model also said: “Published case studies of ‘successful treatment’ of children expressing gender incongruence must be interpreted while keeping in mind that gender identity does often continue to evolve during development, and many children with prepubertal gender incongruence will spontaneously identify with the birth-assigned sex as puberty approaches, without any kind of ‘treatment’.”

Those passages advising restraint did not appear in the ensuing September 2021 model of care, which appears to still be in use. That new model of care recommends that social transition be child-led, and says that, “A small body of evidence suggests that children living in social transition can have good mental health.” However, the 2021 model was more prescriptive about the legal rules governing the medical transition of minors, urging uncertain clinicians to consult the State Solicitor’s Office.

An affirmative medicine chest

Canada | A First Nation group in the province of Alberta has announced a “safe haven” on its reserve land for youth seeking gender medicalisation. In 2024, the provincial government led by Premier Danielle Smith sought to protect young people by banning puberty blockers and cross-sex hormones under age 16 and restricting trans surgery to those 18 and older. To justify its challenge to provincial law, the Saddle Lake Cree Nation invoked the “medicine chest clause” of an 1876 treaty.

Bloody obvious

United Kingdom | Transgender surgery has been suspended, pending review, at the only National Health Service (NHS) adult gender clinic in Wales, journalist Nick Wallis reports. “This is no longer just a debate about the ethics of the NHS helping unwell people chop up their genitals or slice off their breasts,” Wallis says. “This is about basic clinical competence. And it looks like the Welsh Gender Service couldn’t even manage that.”

The initial concern was a surgery referral rate significantly higher than English gender clinics. It emerged later that, compared to English patients, a lower proportion of the Welsh were progressing to surgery. “This raised questions about why more patients were being referred from Wales and whether some patients who were not going on to have surgery had been appropriately assessed before referral,” NHS Wales said.

“Furthermore, information provided by clinicians and correspondence received, raised concerns about whether some aspects of the assessment process before referral had been completed appropriately. These concerns included whether some patients met the basic requirements for surgery, including factors such as BMI and overall surgical fitness, and whether wider health needs had been fully considered before referral.”

Prompted by the revelations in Wales, a mental health clinician spoke to Wallis about her experience working as a team leader at an NHS adult gender clinic. Speaking anonymously as “Anna”, she had expected the clinic to do psychological formulation, starting with an understanding of why the patient wished to transition. Instead, she found the process involved a fixation on diagnosis alien to mainstream practice.

“Somebody I remember very, very clearly, was a young woman, who was identifying as a man,” Anna said. “She had very large breasts, and she wanted cross-sex hormones. She wanted testosterone and she wanted her breasts to be removed. Okay.

“But her history was that she had been sexually abused for many years by her father, and the sexual abuse was around her breasts. It’s so bloody obvious. I could stand next to somebody at a bus stop and say, ‘What do you think of that?’ And they’d say, ‘Of course, you’d need to think about the sexual abuse.’ Of course you would. But at the gender clinic, she met the diagnostic criteria for gender dysphoria. So, she went through.”

Justice on the case

United States | Mount Sinai Health System in New York has agreed to cease the provision to minors of puberty blockers, cross-sex hormones and trans surgery, as part of a settlement with the Trump Administration’s Department of Justice. “Mt Sinai will also pay a monetary penalty and dedicate US$2 million to providing free medical care to individuals suffering harmful consequences of ‘gender affirming care’ they received as children,” the Department said. Commentator Leor Sapir has analysed the controversy over the Mt Sinai agreement.

Similar settlements—following investigations of what the Department describes as “sex-rejecting procedures” on minors—have been reached with other hospitals. On September 22, The New York Times reported that “at least six hospitals have struck agreements with the Trump Administration to pay fines and stop providing gender-transition treatments to minors”.

The Department of Justice has also begun action in what may prove a test case to prevent schools presiding over social transition of pupils without telling parents. The argument is that guidance used in Kansas City, Kansas Public Schools (KCKPS) breaches the Family Educational Rights and Privacy Act, which guarantees parental access to student records, and the Protection of Pupil Rights Amendment, which stipulates that minors cannot be required to do a survey or evaluation revealing sensitive material without prior consent of their parents.

Pole position

The Netherlands | The activist group Transvisie was involved at an early stage in the development of the 2019 Dutch Quality Standard for Somatic Transgender Care, while insurers were kept at a distance, according to Freedom of Information documents reported by Hermes Postma. Writing for Inspecting Gender, he says: “Insurers were the party most likely to ask hard questions about long-term outcomes, complications, evidence quality, controllability of indications, aftercare, and whether treatments can responsibly be purchased as insured care.”

Blowback

Australia | A draft law criminalising “conversion therapy” in the state of Tasmania may catch practitioners of gender-affirming care, including those transitioning minors at the government-run Tasmanian Gender Service, according to Emeritus Professor of Law Patrick Parkinson.

In his analysis of the bill proposed by the island state’s Greens Party, he says: “The nature of the irreversible treatments of hormone therapy and surgery is that the body is changed to be congruent with the sex with which the person identifies. The effect of that, in turn, is to change their sexual orientation …

“It has been a very common complaint of those who regret their gender-affirming care that the treating clinicians did not recognise that their gender non-conformity was really just an emerging same-sex orientation. The adolescent years are a time of identity formation and development, and all the research shows that sexual orientation, at this stage, is quite fluid and changeable.”

Damage done by ‘T’

International | Writing for Genspect, retired midwife Robin Jones enumerates the potential effects of male-level testosterone, known as T, on a female body. These include pelvic floor dysfunction, incontinence, urinary tract infections, and vaginal atrophy. “Too much testosterone does not make a woman into a man, but it does create health problems associated with a lack of oestrogen in menopause,” Ms Jones writes.