Blockers on trial

Plus: Genital surgery on US teens; Dutch Health Council rebuked; the incoherence of gender identity; Brazil's cancel culture; sterilisation v German law; tomboys lost to trans; medical misinfo in Oz

GCN global briefs

Renunciation

United Kingdom | The puberty blocker trial recommended by the Cass Review can go ahead following the failure of a legal challenge to ethical and regulatory approval of the trial. Some 226 minors with “gender incongruence” and under the age of 16 are to be recruited, and randomly assigned to two groups: the first receiving blockers straight away, the second after 12 months.

The legal challenge was brought by the parents’ organisation Bayswater Support Group, detransitioner Keira Bell and therapist James Esses. Their request for a full judicial review was rejected on Friday by Justice Chamberlain of the High Court, who said whether to approve the trial was “quintessentially a question of judgment” for the Health Research Authority (the HRA gave ethical approval) and the Medicines and Healthcare products Regulatory Agency (the MHRA conferred regulatory approval).

The judge said: “The court’s function is not to say whether it agrees with the decision under challenge, but rather to examine whether the defendant [the HRA and the Health Secretary on behalf of the MHRA] has exercised their function contrary to the legislative scheme or otherwise unlawfully.”

Bayswater Support Group said it still believed the trial “does not meet the legal and ethical thresholds required for research on children”. It said the Declaration of Helsinki on clinical trials was “not intended to permit experimental interventions on highly vulnerable children simply in order to discover whether benefit exists”. Ms Bell said: “The push for this trial represents one aspect of a profound descent into the desecration of our humanity. The protection of children should be an inviolate principle, but this clinical trial tells a different story … We will be consulting as a team regarding the possibility of an appeal”. For news reporting of the case, see Nick Wallis. For commentary, see Transgender Trend.

In a parliamentary briefing paper, Baroness Cass, the paediatrician who led the 2020-24 review of youth gender dysphoria care, has presented a detailed argument for going ahead with the blockers trial. On the phenomenon of self-medication, she says up to 20 per cent of young patients at the new National Health Service gender clinics admit to taking a range of medications, including drugs as substitutes for puberty blockers. She says oestrogen and testosterone are being used as cross-sex hormones as young as 11-12 years old, “some on very high doses, resulting in biological females developing facial hair by 13. In most cases there has been a lack of any monitoring, and of any evidence of consent.”

“In summary, taking the young people we know about, and the much larger number that we only have an inkling of from anecdotal reports and comments from Dr Helen Webberley about the GenderGP [online clinic] caseload, the relatively small numbers who might be enrolled and closely monitored and supported in a trial are dwarfed by the hundreds who are currently on cocktails of drugs from elsewhere with no support or monitoring. These risks are immediate and deeply worrying.

“It was suggested in parliamentary debate that this is the same as taking cocaine, and we would not prescribe it just because children were getting it on the street. However, we have to take responsibility for the fact that we have given unevidenced messages about treatment options, failed to address unacceptable waiting lists for this very vulnerable group, banned the drugs that we told them were essential and not yet followed through on commitments that were made for a safe prescribing environment.”

Stop it now

America | The watchdog group Do No Harm has called on ten medical associations—including those representing paediatricians, obstetricians and gynaecologists, and urologists—to renounce genital surgeries on gender-distressed minors. An analysis of health insurance data from 2019 to 2021 showed 56 genital surgeries in minors aged 13 to 17.

In its July 29 letter to medical associations, Do No Harm’s Dr Stanley Goldfarb says: “For adolescents, who lack the capacity to provide informed consent or even assent, these exceptionally high-risk procedures—characterized by significant rates of complications and lacking any benefit—should not be included in any clinical-care plan or treatment protocol.”

Dubious diagnosis

The Netherlands | The Dutch protocol for paediatric medical transition is afflicted by unclear diagnosis and tendentious language, according to Dr Armand Girbes, the former head of the intensive care unit at the university hospital VUmc, which is home to the famous Amsterdam gender clinic.

Dr Girbes, a consultant in internal medicine and a clinical pharmacologist, has written a sharp criticism of the Dutch model and its defence by the independent Health Council of the Netherlands. (He was a signatory to the June 25 opinion article in the newspaper Trouw, which argued that the Dutch could no longer ignore the international shift towards a more cautious, less invasive response to gender-distressed youth.)

Writing for the publication Wynia’s Week, Dr Girbes says: “An accurate diagnosis is not only necessary to choose the right treatment, but also to prevent an incorrect treatment from masking or even exacerbating the actual condition. In children and young people who present with feelings of gender dysphoria, that diagnosis is often far from clear. This is all the more important now that this group is much more likely to also have other symptoms such as autism, depression or ADHD.”

“The resulting question is therefore: is gender dysphoria the primary diagnosis here, or is it a symptom of something else? That question must be addressed before any irreversible medical intervention is undertaken.

“All of this is of the utmost importance in order to comply with one of the most fundamental principles of medicine: primum non nocere—first, do no harm. Hormone treatments and surgery in children and adolescents cause irreversible damage, including infertility, sexual dysfunction, bone problems, an increased risk of cardiovascular disease, lifelong dependence on medical care and, not least, a risk of death. Anyone proposing such interventions bears a heavy burden of proof.

“After thirty years of the Dutch Protocol, that burden of proof has still not been met. The uncertainty surrounding the diagnosis itself is systematically underestimated. Is gender dysphoria in a teenager a primary, stable identity disorder that needs to be confirmed? Or is it a symptom of something else: autism, trauma, depression, ADHD, social influence via peers and the media, or the normal confusion of puberty?”

Dr Girbes contrasts the seeming confidence of the Dutch gender clinicians with the international scrutiny of their foundational studies. The Health Council, which confirmed the weak evidence base, found no reason to cease these hormonal treatments, affirming them as well organised.

Dr Girbes says the council’s report “acknowledges that the level of evidence is low and refers to international developments, but then concludes that the Dutch approach is ‘careful’ enough to be largely continued. That is precisely the disdain of a ‘leading’ nation: foreign systematic reviews and thorough peer-reviewed analyses are noted, but not deemed decisive. After all, we do it more carefully.”

“It is striking in this context that the manifesto of D66—the [centre-left] political party that seems most committed to the Netherlands’ role as a leading nation in areas such as transgender care (for young people)—states that care whose effectiveness has not been proven must be scrapped. The CDA and VVD [centre-right parties] also support this.

“Logically, this means there is no credible reason to maintain the current medical gender care for minors. After all, high-quality systematic reviews conclude that the evidence for puberty blockers and cross-sex hormones in young people is low to very low: there is no convincing evidence of lasting improvement in mental health, suicidal tendencies or quality of life, whilst the risks of infertility, sexual dysfunction and impaired bone development are real and largely irreversible.”

Dr Girbes suggests that the Health Council has compromised its independence and allowed “ideological convictions” to trump the scientific evidence. He highlights the role of biased language—for example, teenagers are said to be “assigned male at birth”.

“It suggests that sex is arbitrarily ‘assigned’ at birth rather than biologically observed, and that the medical interventions are, by definition, ‘affirming’ and therefore positive. This choice of words is not scientific progress, but an ideological shift that frames the entire treatment model as self-evident and harmless. After all, anyone who criticises ‘gender-affirming care’ appears to be against care. Referring to androgens and/or oestrogens as ‘gender-affirming hormones’ also falls into this category.”

---

Trans spectrum: “What I found was that the transsexual males, the ones who were certain that they wanted to be women, were all autistic”—psychiatrist Dr Az Hakeem

Whose theory?

America | In an essay for Skeptic magazine, author Lisa Selin Davis highlights an overlooked conundrum of gender transition. She writes: “Among the most important issues with pediatric gender medicine is what is being treated. If originally transition was to alleviate distress, and make it easier to pass, those goals have largely been discarded in the face of a revolutionary approach to gender identity—not just male and female, but dozens of neo-identities and pronouns like xi and xir to match.”

“Few proponents have stopped to ask what gender identity is, and to question whether everyone has one. In fact, there are several theories of gender identity. One is that it’s simply an awareness of one’s sex—and one would need such an awareness in order to be distressed about it.

“Another is that it’s a cognitive phase, when toddlers become aware that there are two sex categories, and that they belong to one or the other. They base their sense of what category they belong to on their adherence to gender norms. By around age six or seven, that phase cedes to another: gender constancy, when kids realize their category is based on bodies, not stereotypes.

“The third theory is that gender identity is a sense of oneself as man, woman, both, neither, or some other category, completely independent of the body. This theory has prevailed, and remained largely unquestioned—but it needs to be. That is a subjective belief—one anyone is entitled to. But it is not an objective fact, as biological sex is.

“Still, many young people, including those who’ve gone to medical school, were reared with this version of gender identity as an indisputable reality, and do not understand that it is a political category, not a biological one. Clinicians, teachers, parents, and patients should be informed of these various competing theories, and not simply taught one of them as a fact.”

Circular definition

Sweden | Psychiatrist Mikael Landén, an author of Sweden’s 2023 systematic review of the weak evidence for puberty blockers and cross-sex hormones, has written a new paper on the “poorly defined” concept of gender identity and its implications.

Professor Landén, from the University of Gothenburg and the Karolinska Institute, writes: “Existing definitions typically describe [gender identity] as a person’s internal sense of gender without independently defining gender itself, making the concept difficult to operationalise and distinguish from related constructs.”

“For most people this conceptual ambiguity has little practical consequence. They know themselves to be male or female without experiencing this as a distinct identity. Nor did it matter greatly when gender dysphoria was a rare condition affecting a small and relatively homogeneous group of adults with a persistent conviction that they belonged to the opposite sex.

“It becomes considerably more consequential, however, when the poorly defined concept of gender identity is applied to a rapidly growing and clinically heterogeneous population of children and adolescents.” The Society for Evidence-based Gender Medicine has published an analysis of the Landén paper.

Rhetoric v reality

The Netherlands¹ | A former clinician at the Amsterdam VUmc gender service, clinical psychologist Dorine Sellenraad, says she doubts the Dutch claim to greater caution than their overseas colleagues when it comes to gender dysphoria diagnosis and treatment. She worked in the clinic from 2000 to 2001 with adult patients. “Leading clinics such as the VUmc should advocate for psychological transgender care, but they do not,” she told GCN.

“What I hear is that the regular gender therapists are inclined to conduct young adults into the somatic pathway [of hormones and surgery] when these young adults ask for exploration.

“What we practitioners in [specialist mental health care]—who work with young adults (18-25)—see more and more is that these young adults who are referred to us with a possible autistic disorder, trauma complaints, anxiety, sadness and personality problems, also have a somatic treatment process going on for gender dysphoric complaints, whether or not at the VUmc.

“These young adults themselves make no connection between the various problems and their gender dysphoria and most of the time we are not being approached for consultation by the gender therapists. Now it may be the case that patients themselves do not say anything about other problems to the gender practitioners. This is one of the reasons why a good diagnostic procedure [that includes taking a patient’s history from sources other than the patient] is required.”

Also a signatory to the Trouw opinion article, Dr Sellenraad said she attended a 2024 meeting at the VUmc where the case of a patient with gender dysphoria and several other problems was discussed. She said she was struck by the ease with which a VUmc clinician had recommended hormones.

“I fear that the Health Council [in its recent report on paediatric medical transition] relies too much on what is said and written, and has not investigated enough how it works in practice.” GCN sought comment from the VUmc clinic’s senior psychiatrist, Dr Annelou de Vries.

Genspect’s Inspecting Gender has published a critical profile of medical psychologist Dr Peggy Cohen-Kettenis, a pivotal figure in the development of the puberty blocker-driven Dutch Protocol. In January 2024, Dr Cohen-Kettenis said that funding from Ferring Pharmaceuticals did not influence Dutch research on puberty blockers. “In case of any signs of negative effects [from blockers] we would have ended the protocol,” she told GCN.

Save the date

New Zealand | On October 17, psychotherapist Dr Stella O’Malley will be the keynote speaker at Genspect NZ’s conference “Their future. Our responsibility. Children, adolescents and gender identity”.

Third degree

Brazil | Celina Lazzari, co-founder of MATRIA Brazil, a sex-realist women’s group, had to fight in the courts to secure her PhD after she was targeted by activists over her opposition to paediatric medical transition, Reduxx magazine reports.

MATRIA’s other co-founder, Clarice Saadi, says this is not an isolated case, with her group supporting “many researchers who have been silenced, pressured, or discouraged from conducting studies that critically examine issues related to the sex-based rights or trans ideology”. Ms Lazzari’s doctoral research found that social workers “had a tendency to identify children as transgender prematurely” and that “affirmative gender theories exert a strong influence on this process”.

Meanwhile, Genspect has begun to offer its Beyond Trans online support groups in South America.

Rule of law

Germany | A legal analysis by Professor Liane Wörner of Konstanz University and her colleagues warns that treatment of minors with puberty blockers, cross-sex hormones or trans surgery is “highly controversial in terms of their benefits, risks and legal admissibility”.

The Journal of International Criminal Law published her paper in 2025 but it was recently shared by a prominent German child and adolescent psychiatrist. The paper invokes Germany’s civil and criminal prohibition on the sterilisation of minors.

“High standards must therefore be applied to medical indication, risk-benefit assessment, capacity to consent and legal admissibility—in the tension between self-determination and the best interests of the child.” The authors cite “the absence of reliable data” when considering whether puberty blocks themselves offend the sterilisation ban.

“However, a significant risk of criminal liability remains, as the almost invariably subsequent continued treatment with cross-sex hormones [after puberty blockers] threatens the loss of reproductive capacity. Ultimately, this remains sufficient to establish the conditions for a causal link between the risk and the actual occurrence of grievous bodily harm involving the loss of reproductive capacity (Section 226(1)(1) of the German Criminal Code).”

Tomboys at risk

The Netherlands | In the newspaper De Volkskrant, sociologist Jolande Withuis deplores the illogical nature of the Dutch Health Council’s findings and advice on the gender medicalisation of minors. “It states, in fact, that whilst there is admittedly no scientific evidence for the current treatment of children with gender dysphoria, and whilst we still know very little about key issues (such as the long-term consequences of hormone use and regret), we must, above all, carry on with it. This appears to be a political compromise—not least regarding a medical treatment with far-reaching consequences.”

She also laments the failure of the council to explain the switch in patient profile to chiefly female teenagers. “My feminist heart breaks when I think of a ‘tomboy’—a boyish girl—who is in love with a female friend and is bullied at school by ultra-feminine little bitches who get up at six o’clock to apply thick layers of make-up, as dictated by influencers. Such a girl—who may well be a lesbian—can now easily conclude that she needs to ‘transition’ because she was ‘born in the wrong body’. After all, that fashionable slogan is being thrust upon her from all sides.”

Amnesty’s smear

United Kingdom | The group Thoughtful Therapists—one of several organisations critical of paediatric medical transition and targeted by an Amnesty International UK report—has rejected its classification as a promoter of “conversion therapy”.

In a July 10 letter to Amnesty from Thoughtful Therapists, Peter Jenkins says Amnesty’s “report does not define conversion practices at any point, nor does it provide substantive evidence that our organisation participates in any way, shape, or form in so-called conversion practices.”

“Given that the current [UK] Draft Conversion Practices Bill CP 1604 has just been published by the Cabinet Office, this seems calculated to link our organisation to potentially illegal activities, but without providing a scrap of evidence. As in the case of the Red Queen in Alice in Wonderland, ‘Sentence first, verdict afterwards’.”

Other groups smeared as part of an “anti-rights movement” include Genspect and the Society for Evidence-based Gender Medicine. On Friday, Amnesty made a public apology for the report while internally seeking to appease activists.

Defiant gender clinics

Sweden | Dutch-style early transition of minors became routine without any study comparing this invasive model with the previous, more cautious “wait and see” approach, according to Agnes Wold, who is a senior physician, commentator on health, and professor of clinical bacteriology at Sweden’s University of Gothenburg. In an article published by the newspaper Expressen, Professor Wold surveys the history and ethics of the widely adopted Dutch Protocol for paediatric medical transition.

She writes: “This large-scale experiment has been ongoing for a quarter of a century in Sweden and the Western world. It was launched without any evidence of its effectiveness or safety. Once the clinics had opened, they attracted various groups of confused young people who believed their problems could be cured by gender reassignment.”

“At a group level, no benefit from the treatment can be demonstrated, whilst there are numerous side effects; at an individual level, it is impossible to identify who might actually be helped. The treatment is therefore ethically indefensible. It is high time to bring the experiment to an end.”

Professor Wold questions the effect of the new, more cautious treatment advice issued by the National Board of Health and Welfare in 2022. She says “clinics have not heeded this advice: more children are being given sex hormones now than before the advisory was issued. For although fewer girls are receiving testosterone, a greater number of boys are receiving oestrogen. And more boys than ever are now being given puberty blockers, contrary to the recommendations.”

No blank cheque

Australia | The federal Opposition has sounded a cautionary note in advance of the first national advice on the use of puberty blockers for gender distress. The National Health and Medical Research Council (NHMRC) is due to issue interim advice on blockers by end-August with the new treatment guideline in its full and finalised form to be finished in 2028.

Liberal Party Senator Anne Ruston, the shadow health minister, said the Opposition’s support for the NHMRC project was not “a blank cheque”. In a statement to The Australian newspaper, she said: “Given how significantly the international landscape has shifted, Australians need confidence that there is not just a light-touch update of the current guidelines. It must be grounded in well-conducted systematic reviews of the evidence base, and the reasoning and evidence [should be] made public alongside the advice, not released after the fact.”

Writing for The Australian, I also reported the startling claim by the country’s chief medical officer, Professor Michael Kidd, that “Puberty blockers, as we know, can be lifesaving care for many young transgender people.” He said this in December 2025 during a Senate estimates hearing in which the NHMRC project was mentioned. The Kidd claim, unsupported by the weak evidence base, had gone unreported.

Ahead of the NHMRC’s puberty blocker advice, coverage by the public broadcaster the ABC allowed a hint of clinical dissent, while suggesting that blockers are reversible and the critics of gender science are limited to populist-right politicians.

In the ABC News article, there was one reference to systematic reviews showing the evidence for blockers to be poor, without any explanation of the nature and significance of these systematic reviews across quite different health jurisdictions.

As for the statement that blockers are reversible, even the gender-affirming clinic of the Royal Children’s Hospital Melbourne has abandoned such an unqualified claim and has admitted in a newsletter to patients and parents that the effects of puberty suppression on the still-developing adolescent brain are unknown.

It’s cosmetic

America | In a journal article, evolutionary biologist Dr Carole Hooven and philosopher Professor Alex Byrne document the effects of trans identity politics on understanding of the sex binary with its male and female gametes.

On gender medicine, they say: “Patients are poorly served by confusions about fundamental aspects of biology; in particular, they deserve to be told that ‘gender-affirming’ medical treatments are cosmetic, rather than being allowed to think that sex is ‘mutable’. That alone does not restrict treatment options, but honest communication with patients is a standard precept of medical ethics.”

Language games

The Netherlands | In the OpinieZ magazine, Johan Bolhuis, Affiliated Professor at the University of Cambridge and Professor Emeritus of Cognitive Neurobiology at Utrecht University, suggests that conflicts of interest have impaired the independence of the Dutch Health Council committee tasked to give advice on paediatric medical transition. “Although the committee consists solely of academics, its report is rife with unscientific terms such as ‘gender identity’, ‘cisgender’ and ‘sex assigned at birth’,” he writes. “By consistently using this terminology, the impression is given that these are factual scientific concepts.”

“The [council’s] report seeks to paint a picture that transgender care in the Netherlands—the birthplace of the Dutch Protocol—is in excellent order, in contrast to neighbouring countries. In our country, puberty blockers and hormones are said to be a last resort, used only when long-term therapy proves insufficient.

“The reality is quite different. A recent study by the Amsterdam UMC [gender clinic] shows that 82 per cent of adolescents who registered at the gender clinic between 2009 and 2019 went on to undergo medical transition. Apparently, the ‘(…) carefully structured process, with an extensive exploratory and diagnostic phase, careful assessment of indications and support from multidisciplinary teams’ has little effect on the vast majority of adolescents.”

1. I am running four items from the Netherlands—home to the source of the internationally adapted Dutch Protocol—because of the significance of the Health Council’s recent, contentious report, and the strong criticism it has engendered.