Genderbusy

Guideline dissent in Germany; US whistleblowing doctor on charges; not-so-immutable gender ID; calling the bluff of gender research; an ethics review in the Netherlands; and more Cass Down Under

Photo by AbsolutVision on Unsplash

GCN in brief

Guideline in trouble

Germany & Switzerland | Medical societies in Germany and Switzerland have advised caution on the gender medicalisation of minors and called for revision of German-language draft treatment guidelines that would liberalise access to paediatric transition. Taking up a contrary position, the board of the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPM) said hormonal and surgical interventions should be kept to “a small number of cases”, involve mandatory multidisciplinary assessment and be restricted to clinical studies.

The DGPPM bills itself as Germany’s largest scientific medical association focussing on mental health. The “gender-affirming” draft guideline, developed under the leadership of a smaller professional group—the German Society for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy (DGKJP)—is beset by increasing challenges. Another request for revision comes from the Swiss Society for Child and Adolescent Psychiatry and Psychotherapy, which has aligned itself with a recent statement of the European Society for Child & Adolescent Psychiatry urging healthcare providers “not to promote experimental and unnecessarily invasive treatments with unproven psychosocial effects and, therefore, to adhere to the ‘primum nil nocere’ (first, do no harm) principle.”

Affirmative lawfare

America | A doctor who alerted a journalist to a secret expansion of gender medicine at Texas Children’s Hospital is being prosecuted by the US Department of Justice. The doctor, Eithan Haim, said he felt he had to act when he realised that medical transition of children was continuing despite the hospital’s public claim it had put a stop to these medical interventions. He recorded an online presentation in which a hospital social worker stated she did not include treatment on medical charts, so as not to leave a compromising paper trail. “They were talking publicly about how they were concealing what they were doing,” Dr Haim told The Free Press. “You can’t take care of your patient without trust. For me as a doctor, to not do something about this was unconscionable.”

Before giving journalist Christopher Rufo proof that puberty blockers were still being implanted, Dr Haim said he redacted personal details from patient documents. Last year, however, federal agents from the Department of Health and Human Services—which promotes “gender-affirming care” for minors disregarding its weak evidence base—told him he might be investigated for allegedly violating a federal law, known as HIPAA, that protects the privacy of medical records. Dr Haim saw this as “a blatant attempt at political intimidation”. Last week, US marshals came to his home and called him to court to face an indictment on four felony counts of breaching HIPAA. Dr Haim has launched a crowd-funding appeal to finance his defence and “to establish a precedent for other whistleblowers to speak out without fear of government persecution.”

Video: The American College of Pediatricians has launched a Doctors Protecting Children Declaration warning against the harms of medicalised gender change. The college is a smaller, more conservative rival to the “affirmation-only” American Academy of Pediatrics

Desistance pays off

Germany | A new, unusually comprehensive study from Germany reports that gender distress was often resolved in a large group of young patients over a five-year period. Using health insurance data, the researchers found an eight-fold increase in the prevalence of gender identity disorders—F64 diagnoses under the ICD-10 classification—over the period from 2013 to 2022 among patients aged 5-24 years.

However, among 7,885 patients, only 27.3 per cent of females aged 15-19 and 49.7 per cent of males aged 20-24 still had an F64 diagnosis after five years. The desistance rate across the sexes was 63.6 per cent. The researchers attributed the relatively low persistence rate to “the fluidity of the concept of ‘gender identity’ in childhood and adolescence”. However, they said the finding was also a reminder of the need for a “comprehensive, standardised diagnostic procedure”, and cited the Cass report in this context. The parents’ group Our Duty commented: “With such high rates of desistance, the case against the medicalisation of gender incongruence just became even stronger than was made out in the Cass review.” (Update: For a note of caution in interpreting this German study, see here.)

A first for detransitioners

America | A judge in North Carolina has allowed detransitioner Prisha Mosley’s fraud claims against her doctors to progress. Her lawyers, Campbell Miller Payne, who specialise in pursuing claims arising from gender medicine, said it was “the first substantive ruling we are aware of in which a court has held that a detransitioner’s case against her healthcare professionals is legally viable.” On May 7, Judge Robert C. Ervin of the North Carolina Superior Court granted motions by defendants to dismiss some of Ms Mosley’s claims, including medical malpractice, but three claims of fraud, facilitating fraud and civil conspiracy were left standing. In his pre-trial ruling, Judge Ervin found that these three allegations, “treated as true, are sufficient to state a claim upon which relief may be granted.”

Ms Mosley’s story is that, from the age of 16, she had been put on a path of medicalised gender change by health professionals. “They told me that changing my body to look like a boy’s body would cure my mental health problems,” she wrote in an opinion piece last year. “They told me that injecting large amounts of testosterone into my female body would be good for me. They also encouraged me to undergo surgery to remove my healthy breasts.” Years later, she said, she realised she had been misled and that gender medicine had left her with “extreme physical injuries and without my body parts. It did not cure my mental health problems and instead made them worse.”

Video: Lawyer Josh Payne of Campbell Miller Payne talks to therapists Stella O’Malley and Sasha Ayad about the emerging field of detransitioner litigation

Deflating the hype

International | A new paper has scrutinised studies typically invoked to claim that gender medicine confers “lifesaving” benefits to mental health. In her review of 14 studies reporting outcomes for depression and/or suicidality after hormonal treatment, researcher Dr Kathleen McDeavitt detected a trend to declare mental health benefits for gender-affirming interventions “even in context of results which showed statistically insignificant findings, minor improvement, or negative outcomes”. She highlighted the 2022 study of Tordoff et al, which she noted had claimed improvement “even though study results showed no significant change in depression or suicidality outcomes over time.”

Dr McDeavitt challenged a fallback argument made by gender-affirming advocates when they are presented with multiple systematic reviews showing the evidence base to be very weak and uncertain. For example, she cited a recent bioethics paper acknowledging the dispiriting outcome of systematic reviews but asserting “that the evidence proffered by existing low-quality studies has consistently demonstrated improved mental health with hormonal intervention, and is therefore sufficient for the purpose of underpinning the affirmative care model.” Dr McDeavitt said her review contradicted this claim. She said the observational studies under review, “in addition to comprising low-certainty evidence, do not demonstrate consistent correlation between hormonal intervention and improvement in depression and/or suicidality outcome data. Most studies did not report significantly positive depression outcomes, only two studies reported significantly positive suicidality outcomes, outcomes were negative in the largest study, and there were two patient suicides in the most recent study.” Dr McDeavitt concluded that the “true impact” of hormonal treatment on depression and/or suicidality among gender-distressed young people remained unknown.

Wrangling Cass

Netherlands | The Health Minister for the Netherlands, Pia Dijkstra, has sought to play down the implications of the Cass report for the country whose “Dutch protocol” of medicalised gender change has been adopted and liberalised internationally. In a June 4 letter to the speaker of the lower house of parliament, Ms Dijkstra suggested that England’s Tavistock clinic fell below the standards set by its Dutch counterparts. And she claimed that the catch-up research called for in Finland, Sweden and England was “already being done in the Netherlands.” She also summarised a joint response to the Cass report from Dutch clinics, in which they claimed that medical treatment “can actually help reduce symptoms” of serious psychological problems affecting dysphoric children. (That claim is at odds with the systematic evidence reviews undertaken independently in Finland, Sweden and England.) Minister Dijkstra said she had “every confidence that [Dutch] healthcare professionals take extreme care” when providing gender medicine.

However, in response to two sceptical motions passed by the lower house, she said: “I, too, see the dilemmas associated with transgender care for minors and attach great value to an opinion from the Health Council on this issue.” It was parliamentarian Diederik van Dijk of the Calvinist Reformed Political Party (SGP) who in January put up the successful motion that the country’s independent Health Council measure gender medical practice against the health law framework. In February, the lower house passed a separate motion— submitted by New Social Contract member Dr Rosanne Hertzberger—calling for research to compare Dutch protocol outcomes with the results of new, more cautious treatment policies elsewhere in Europe. Minister Dijkstra said she was giving effect to both motions by asking “the Health Council to advise me on the elements mentioned in the motions, such as the use of the Dutch-protocol methodology.” The council was expected to begin the advisory process this year. A new Dutch government is expected soon, following a shift to the political right in last November’s elections.

Psychology underdone

United Kingdom | The UK Association of Clinical Psychologists (ACP-UK) has endorsed England’s “impressive and comprehensive” Cass report and its associated systematic evidence reviews, noting that the four-year project was guided by “the highest clinical and research standards available at this time.” ACP-UK said clinical practice at the London-based Tavistock gender clinic “did not always employ standard psychological approaches such as psychological formulation and close adherence to the available evidence base.” This was “a significant departure from the orthodox modus operandi of the profession.”

ACP-UK highlighted the paradox that, although the Tavistock clinic was psychologist-led, it “employed predominantly medical/endocrinological interventions, often with insufficient consideration of psychological factors.” For ACP-UK, the approach to gender identity “must take account of the developmental stage of the individual, with marked differences between those presenting during childhood, adolescence and adulthood.”

Not so psyched

Australia | The Royal Australian & New Zealand College of Psychiatrists (RANZCP) has opposed the idea of an independent investigation of paediatric gender services Down Under informed by the Cass report. A letter to the college from 17 members said, “we believe our serious professional concerns regarding the gender interventions being provided to Australian children and adolescents are not being adequately represented by the college in its media communications and political advocacy.” Almost two weeks after the release of the Cass report, the RANZCP quote tweeted a Guardian Australia article suggesting Dr Cass’s concerns were remote and of little local relevance. The college’s Twitter comment was: “In light of the findings of the #CassReview in England, it is important to acknowledge the stigma and discrimination faced by trans and gender-diverse people and make clear that being trans or gender-diverse is not a mental health condition.” In the Guardian article itself, RANZCP president Dr Elizabeth Moore was quoted to similar effect. No public statement addressing the substance of the Cass findings has been forthcoming from the college.

On May 29, however, the RANZCP website reproduced the 17-member letter urging the college to acknowledge the relevance of the Cass review and to “call for health ministers to establish an independent body to investigate Australian paediatric gender services and implement relevant recommendations from the Cass review.” A reply from the president, Dr Moore, said the college supported development of a nationally consistent framework for gender medicine, but not a request for a government-commissioned inquiry. Gender dysphoria policy has divided the college ever since September 2019 when it quietly deleted its public endorsement of puberty blockers and the gender-affirming “Australian standards of care” treatment guidelines issued by the Royal Children’s Hospital (RCH) Melbourne. Those guidelines had been the subject of media scrutiny in The Australian newspaper.

Irrelevant, but we’ll have a look

Australia | The Health Minister of Victoria, Australia, Mary-Anne Thomas, has claimed that “misinformation” about gender medicine “has got worse” since the release of England’s Cass report. She said provision of gender care in Australia was “profoundly different” from delivery in the UK and other countries. Even so, she said her department was “considering the applicability of the [Cass] report’s recommendations to the Victorian context.” In response to a Victorian petition calling for an urgent independent inquiry into paediatric gender care, Ms Thomas said the 2018 “Australian standards of care” treatment guidelines of RCH Melbourne “are reviewed and updated following new evidence. The most recent update was in 2023.” In fact, the guidelines still cite no new studies since 2018; multiple systematic reviews of the evidence base since 2019 have been ignored. The only updates to the RCH guidelines appear to have been to correct inaccurate legal advice and to give contentious advice that primary care doctors may take the lead in starting 16-17-year-olds on irreversible, lifelong cross-sex hormones without specialist backup. Little has been heard about the first major revision of the guidelines since this was promised in May 2022 by the then RCH gender clinic director, Dr Michelle Telfer. (She stepped down as director later in 2022.) Meanwhile, in the state of Queensland, a government review of the Brisbane-based paediatric gender clinic is expected to report in July. It had been due by April, but it seems more time is needed to consider the April 10 Cass report. The main brief for the Queensland review is to measure the clinic against the RCH guidelines, notwithstanding critics identifying those same guidelines as part of the problem.

Conveyor belt

Australia | A fast-growing gender clinic in Australia’s regional city of Newcastle quickly puts young patients on “the affirmation treatment conveyor belt”, according to NSW Upper House member Greg Donnelly. In a June 6 speech to the Legislative Council, Mr Donnelly cited concerns from local health professionals that the Maple Leaf House clinic was in some cases giving teenagers hormonal treatment after only two appointments. The stand-alone clinic was opened in April 2021 by the NSW government, which has replaced its past, more cautious treatment policy with a rapid expansion of the gender-affirming treatment model. Mr Donnelly said it was “an open secret” that some staff at Maple Leaf House had claimed that the benefit of being a stand-alone clinic separate from John Hunter Children’s Hospital in Newcastle was “to remove [the clinic] from direct, line-of-sight supervision and scrutiny.”

Mr Donnelly said Maple Leaf House, which takes young people up to age 25, reportedly failed to properly assess patients for underlying mental health conditions in need of treatment, and sent them away with prescriptions for puberty blockers and cross-sex hormones without adequate follow up. Mr Donnelly said he had been told the clinic used “strategic legal action or threats of legal action to place pressure on parents to secure support, or at least neutrality, with respect to the facility’s recommended approach to treatment”. He urged “a full, open and independent review” of the clinic, which has failed to supply any data on cross-sex hormone treatment. There is a bill before the NSW parliament which would reduce safeguards for access to gender medicine for minors.