Expert derangement

Eunuch quackery; blots on the Yale white paper; Canada out of line; gender industrial output; Cass on a blocker trial; AAP in a pickle; pushback in Germany; abnormal psych and gender clinics; and more

Photo by Nathan Dumlao on Unsplash

GCN in brief

Eunuchville

America | “Lest anyone mistake it for a scientific medical organization, WPATH [the World Professional Association for Transgender Health] devoted an entire chapter in Standards of Care 8 to ‘eunuchs’—individuals ‘assigned male at birth’ who ‘wish to eliminate masculine physical features, masculine genitals, or genital functioning’.” In a brief intended for the judges of the US Supreme Court, the state of Alabama’s Attorney General Steve Marshall does not hold back.

The case is a constitutional challenge to a Tennessee law that prohibits puberty blockers, cross-sex hormones or trans surgery for minors; a hearing date is yet to be set. The standing of WPATH as a peak medical authority is vital to the law’s opponents. And so, as a “friend of the court,” Alabama seeks to highlight “just some of the publicly available information” about WPATH that led, in its own more advanced defence of a legislative ban like Tennessee’s, to discovery of 2.3 million pages of documents revealing communications between WPATH and senior officials of the US Department of Health and Human Services.

Back to the eunuchs. Alabama’s brief continues: “Because eunuchs ‘wish for a body that is compatible with their eunuch identity,’ WPATH recommends ‘castration to better align their bodies with their gender identity.’ How did WPATH learn that castration constitutes ‘medically necessary gender-affirming care’ for eunuchs? From the internet of course—specifically from a ‘large online peer-support community’ called the ‘Eunuch Archive,’ which WPATH boasts—in Standards of Care 8—houses ‘the greatest wealth of information about contemporary eunuch-identified people.’

“Part of that ‘wealth of information’ comes in the form of the Archive’s fiction repository, which hosts thousands of stories that ‘focus on the eroticization of child castration’ and ‘involve the sadistic sexual abuse of children.’ ‘The fictional pornography’ ‘includes themes such as Nazi doctors castrating children, baby boys being fed milk with estrogen in order to be violently sex trafficked as adolescents, and pedophilic fantasies of children who have been castrated to halt their puberty.’ Despite all this, Petitioners [the parties attacking the Tennessee law] make the remarkable claim that WPATH’s standards ‘were developed in the same way as treatment guidelines for other medical conditions.’ Let’s hope not.” 

The key source relied on by Alabama is journalist Genevieve Gluck’s news report “Top Trans Medical Association Collaborated With Castration, Child Abuse Fetishists” published by Reduxx magazine in May 2022.

Critics critiqued

International | A widely quoted critique of England’s landmark Cass review—a critique often misleadingly cited as the “Yale white paper” as if it bears that university’s imprimatur—confuses the UK tradition of independent reviews with the process for creating a clinical practice guideline, according to a peer-reviewed article by UK paediatrician Dr Ronny Cheung and colleagues published on October 14. This confusion of categories induced the critique’s authors, led by Yale physician Dr Meredithe McNamara, “to claim that the [Cass] review lacks credibility due to its leadership’s lack of experience in transgender healthcare,” the Cheung et al article says.

“However, the independence of the review chair [Dr Cass] from the specific medical field is a key safeguarding measure to prevent bias inherent to working within the field, and to protect patients and the public from the undue influence of these vested interests in the process.” Cheung et al also cite errors of fact by McNamara and her colleagues, including the assertion that guidelines issued by WPATH were rated highly by the Cass review and the claim that the review reported a low detransition rate of 0.3 per cent.

The McNamara paper, Cheung et al argue, is not so much an academic critique as a project to support US litigation against Republican-led states which have banned hormonal and surgical treatments for minors; several of the McNamara paper’s authors reportedly have been paid expert witnesses in this litigation. US journalist Jesse Singal, who has long experience reporting on gender dysphoria, has also been publishing critical commentary on the McNamara paper.

Recycling

Canada | The Canadian Paediatric Society’s “gender-affirming” position statement needs to be urgently updated to bring it into line with “the new international standard of care” represented by Dr Cass’s April report, according to a letter published on October 7 in the paediatric society’s official journal Paediatrics & Child Health. The letter, written by researcher Chan Kulatunga Moruzi and colleagues, notes that the society’s 2023 position statement was too recent to be included in the Cass-commissioned evaluation of international treatment guidelines.

“However, the [Canadian position statement] relies heavily on the Endocrine Society guidelines, the American Academy of Pediatrics position paper, and the World Professional Association for Transgender Health’s Standards of Care (WPATH SOC-8), which Cass criticised for their non-independence and circularity, and [for] using weak evidence to make strong recommendations.” A response from Canadian Paediatric Society members recycles material from the “Yale white paper” critique of the Cass review, including the false claim that evidence favouring gender medicine was excluded simply because the data did not come from randomised controlled trials.

Gender industrial complex

America | The US watchdog group Do No Harm, which opposes ideological incursions in medicine, has launched an interactive database using insurance data to track the number of hormonal and surgical treatments given to gender-distressed youth in the US. An estimated 5,747 minors underwent trans surgery, such as double mastectomy, between 2019 and 2023, while 8,570 received hormones or puberty blockers. The database, which allows searches by state, identifies the 12 children’s hospitals judged to be especially committed to and active in gender medicalisation of minors. The Children’s Hospital of Philadelphia (CHOP) occupies the No 1 spot.

Taken together with recent data analysis by the Manhattan Institute and City Journal, the Do No Harm database suggests that paediatric gender treatment is an industry bigger in scale than previously thought.

Talking up a trial

United Kingdom | Gender-distressed minors will be able to take part in a clinical trial of puberty blockers if their clinicians feel they “may benefit” from these hormone suppression drugs, paediatrician Dr Hilary Cass has said, adding that there will be “no limit” to the number of places available. Such a trial—a proposal linked with Dr Cass’s review of youth gender care in England and Wales—is scheduled to recruit participants next year, if it secures ethics approval.

However, in an October 9 BBC interview, Dr Cass says there has been a “disproportionate” focus on puberty blockers, noting that “the evidence doesn’t show benefit for the majority of young people who go on them.” She also emphasises the need for a mainstream therapeutic approach to distressed youth, rather than a fixation on gender. She recalls that clinicians consulted during her review “were fearful, they didn’t know what to do.”

“Many of them had been told that their only role was to affirm the young person in their identified gender and refer them on to the Tavistock [gender clinic] and, so, just ordinary things like treating depression, treating anxiety, making a diagnosis of neurodiversity, all the things they would do for any other distressed child, they weren’t doing for these young people, which was exceptionalising them…”

Dr Cass says recruitment for more wholistic post-Tavistock services is “slow but steady.” “We’ve got some fantastic clinicians already working in the new services with really broad-based skills. So, they’ve got skills in autism and in young people’s health… The first step is treating these young people just like any other young people in distress and making sure they’ve got those wrap-around services.”

Not what doctors should do

United Kingdom | Theodore Dalrymple, the pen name of a British psychiatrist and chronicler of cultural malaise, has come out strongly against the very idea of a clinical trial of puberty blockers. In City Journal, he writes: “The evidence favoring puberty blockers is lacking, and therefore the use of them is unethical. Moreover, the so-called Dutch protocol [pioneering this use of blockers] was admittedly experimental, and the ethical propriety of experimenting on pubertal children with potentially life-changing drugs thus should be questioned. Indeed, it recalls, admittedly on a much smaller scale and with much less malign intentions, the experiments conducted on children by Josef Mengele. Not only is the evidence lacking; it should remain lacking and should not be gathered or gatherable in the first place.

“The condition is variable, changeable, and nonfatal; it is by no means simply a medical one. In fact, [gender care reviewer Dr Hilary] Cass asks the ethical question as to how far doctors should go in treating with medication and later with surgery a condition that is only marginally medical… No informed consent to treatment can be given, either—first, because the children involved are not capable of giving it; and second, because the information necessary for informed consent is lacking anyway, and probably will remain so.”

AAP in the crosshairs

America | The American Academy of Pediatrics (AAP), which issued a contentious 2018 “affirmation-only” position statement, should immediately retract and correct its “misleading and deceptive” claim that puberty blockers are “reversible”, according to a September 24 letter from Idaho’s Republican Attorney General Raúl Labrador, the attorneys general of 19 other conservative states, and the two legislative leaders of the Democratic state of Arizona.

Citing state consumer protection laws, the Labrador letter to the AAP says: “Telling parents and children that puberty blockers are ‘reversible’ at the very least conveys assurance that no permanent harm or change will occur. But that claim cannot be made in the face of the unstudied and ‘novel’ use of puberty blockers to treat gender dysphoria.” The attorneys note that the AAP policy statement itself acknowledges that “[r]esearch on long-term risks, particularly in terms of bone metabolism and fertility, is currently limited and provides varied results.” The lawyer who writes under the pen name Unyielding Bicyclist offers interesting analysis and context on the AAP’s predicament.

Video: Whistleblower psychiatrist Dr Jillian Spencer explains why she raised concerns about the children’s gender clinic in the Australian state of Queensland

Not normal

Australia | A new paper seeks to explain the rapid rise of risky gender medicalisation through the healthcare concepts of “abnormal illness behaviour” and “abnormal treatment behaviour.” “Abnormal illness behaviour provides a framework for understanding why so many young people now regard lifetime medicalisation as an attractive solution to potentially transitory gender dysphoria, regardless of trauma, internalised homophobia, and other co-morbid psychopathologies,” says the Australasian Psychiatry paper written by psychiatrists Dr Patrick Clarke and Dr Andrew Amos.

“Abnormal treatment behaviour provides a framework for understanding why some doctors and health professionals are so committed to the [gender-affirming approach] despite the limited evidence of benefits, and poorly researched but certainly significant risks of adverse effects and complications, including loss of fertility, loss of sexual function, reduced life expectancy, and regret/desistance/detransition.

“In the [gender-affirming approach], the patient is idealised as the unquestionable gender-identity expert, and the clinician has the subordinate role of uncritical affirmation to facilitate social, medical, and surgical support. As a form of unconscious collusion, this encourages medical and surgical over-treatment, under-treatment of psychiatric disorders, under-investigation of other factors, and may prolong illness over and above the probability of the lifelong trajectory of affirmation interventions.”

Hormonal rush

New Zealand | New Zealand’s Ministry of Health, which is presiding over a long-delayed review of the evidence for puberty blockers, should investigate what appears to be dramatically higher use of these hormone suppression drugs than is the case in either the Netherlands or England and Wales, according to a study published last month in the New Zealand Medical Journal.

The study by emeritus professor of epidemiology Dr Charlotte Paul, Simon Tegg of Genspect and health sociologist Dr Sarah Donovan, says: “From 2009 to 2015, New Zealand had a higher cumulative incidence [the number of patients starting puberty blockers, adjusted for population] than the Netherlands, even though the Netherlands was the first country in the world to use GnRHa [puberty blocker drugs] for gender dysphoria, starting much earlier than New Zealand in the 1990s.

“Over the whole duration from 2009 to 2018, use was 1.7 times higher in New Zealand, reflecting a much steeper increase in prescribing in New Zealand from 2015 to 2018. Compared to England and Wales from 2008 to 2020, the estimated cumulative incidence was 6.9 times higher in New Zealand.

“The main reasons for higher prescribing are likely to be found in our [New Zealand] health system. These could be: easier access to assessment; a lower threshold for diagnosis of gender dysphoria; or greater likelihood of recommending treatment with GnRHa than other treatment options.” The paper by Paul et al was reported in detail by the New Zealand Herald.

Adults should know better

America | On October 11 Women’s Declaration International USA filed an amicus brief in the US Supreme Court test case over Tennessee’s ban on paediatric gender medicine. An excerpt from the brief: “Puberty is not a medical condition. Advocates of ‘gender-affirming care’ have pathologized childhood and confused a generation of children with stories, reality TV, movies, classroom lessons, safe houses, and other stops on the ‘gender medicine’ school-to-clinic pipeline.

“It hardly seems that joining a child (or adult) in his or her flight from reality would be the most helpful or healthy approach to take. Hard truths still must be told: Sex is binary and immutable; the sex you are in your mother’s womb is the sex you will always be; you have one body to carry you through life and there are only so many things you can change about it.

“… it is completely appropriate for government entities, including Tennessee, to take legal measures… to protect children and adolescents from adults who would enforce sex-role stereotypes on girls and boys by diagnosing and treating children as having been ‘born in the wrong body’ when they do not conform to traditional, culturally imposed sex-role stereotypes; identifying young people who are same-sex attracted as suffering from ‘gender dysphoria;’ and using medical interventions on children that may result in their sterilization, loss of sexual function, and other permanent harms.”

Unravelling the zeitgeist

Germany | Despite the perceived power of “trans propagandists,” opinion in Germany is finally mobilising against reckless medicalised gender change for minors, according to the Munich-based child and adolescent psychiatrist Dr Alexander Korte. In an interview with the newspaper Die Welt, marking the publication of his new book Behind the Rainbow, Dr Korte says the “pendulum of the zeitgeist” has begun to swing back following the historic Cass report. He says the gender-affirming treatment approach has been exposed as “child-endangering freestyle medicine without any evidence.”

New trans-affirmative treatment guidelines are due to be published in Germany this northern autumn, but Dr Korte says there is formidable opposition. “Ten professors, many medical specialists and a majority at the German Medical Assembly have announced that they will never, ever follow the guideline in its current form. My colleague [psychiatrist] Florian Zepf from Jena has just pointed out—at the congress of the German Society for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy in Rostock—how ideologically blinded and highly dangerous he considers the guideline to be and that it will not release anyone who makes it the basis of their treatment from liability for their actions.”

Dr Korte, who has been treating adolescents with gender dysphoria since 2004, says the evidence shows that suppressing puberty “blocks other developmental paths, in particular a homosexual coming out and reconciliation with one’s birth gender.” He highlights the fact that the vast majority of children begun on blockers proceed to cross-sex hormones. “This [one-way path] is probably because the drastic, libido-killing effect of such [puberty blocker] treatment means that they have no opportunity whatsoever to gain the crucial experience needed to find a homosexual identity. I find this ethically very questionable.”

Yet another unknown

International | Massachusetts Institute of Technology philosopher Alex Byrne has undermined a key rationale for the gender medicalisation of minors. This is the claim that if childhood-onset gender dysphoria continues into puberty, it is likely to persist into adulthood, unless it is treated with medical interventions.

In a letter published last month in the Archives of Sexual Behavior, Professor Byrne follows the trail of citations said to prove this doctrine and finds the data missing or misleading. For example, in one of the cited studies, most of those described as still “gender-disordered” in adulthood were “clearly gay,” Professor Byrne says. “Is childhood-onset gender dysphoria that persists into early puberty—or, alternatively, worsens with early puberty—highly persistent in adolescence and adulthood if untreated? In the opinion of many experts, yes. But the published evidence does not bear this out. The persistence rate, like the detransition rate, is unknown.”

Video: Genspect USA recently staged a one-day conference on rapid-onset gender dysphoria (ROGD); here, panelists discuss the legal and practical dimensions of ROGD

Research recruitment

International | Young people (aged 13-21) with gender dysphoria and/or their parents have been invited to take part in a longitudinal study of outcomes run by researchers Professor J Michael Bailey, Dr Lisa Littman and Dr Ken Zucker. They note the recent surge in adolescents presenting with gender distress. “This change has been so sudden that several important questions remain poorly understood by scientists, persons with gender dysphoria, and their families. For example: what are the most common outcomes for adolescents and young adults with gender dysphoria? Does this depend on whether birth sex is male or female? Is gender transition associated with long-term happiness? What kinds of differences do parental attitudes and behaviors make?” The study, expected to run for several years, is open to participants from multiple countries.

To be or to conform

International | Exhaustion from the stress of having “to conform to [the] ‘LGBTQ+ community’ and its ideology around gender” is one reason why females decide to begin detransition, according to the latest report from the Bridging the Gap Detransitioner Support Group at BeyondTrans.Org. The group had its origins in contact between Sweden-based mental health counsellor Angelo Vincent Deboni and US detransitioner Laura Becker, and ensuing talks including other detransitioners at Genspect’s 2023 Killarney conference. Mr Deboni presented the 2024 group report at the Genspect Lisbon conference last month.

Dodgy review

Australia | One of Australia’s most distinguished medical scientists TJ “Jack” Martin, emeritus professor of medicine at the University of Melbourne, has put his name to an open letter from 46 doctors, including paediatricians and child and adolescent psychiatrists, highly critical of a government-commissioned “evidence check” used to justify the uncritical expansion of medicalised gender change for minors in the state of NSW in defiance of the Cass report and similar shifts to caution elsewhere in Europe.

Trans train

United Kingdom | The “trans-inclusive” ban on unethical “conversion practices” contemplated by Britain’s Starmer government might subject same sex-attracted girls to the very practice it seeks to prohibit, according to Reem Alsalem, the UN special rapporteur on violence against women and girls.

She cites the Cass report’s warning that a conversion practice ban must not be allowed to stop ethical therapeutic inquiry into the full range of possible causes of a young person’s distress. Otherwise, Ms Alsalem told The Telegraph newspaper, young lesbians may be put on the “high-speed train” of medicalised gender change and “you may inadvertently subject them to the conversion therapy you are trying to ban.”