Global pushback

Italy rethinks puberty blockers; WPATH gets caught out, again; German doctors say No to trans-affirmative medicine; parents mobilise in Chile

Photo by Mario Calvo on Unsplash

GCN in brief

New chief, new scepticism

Italy | A 29-member technical panel set up by Italy’s government to examine the use of puberty blockers is expected to meet for the first time on May 23. The panel includes senior bureaucrats, the leaders of medical societies and bioethicists. Its objective is to standardise treatment across the country with new guidelines. In parallel, the Italian Medicines Agency (Aifa) will review the law that allows the use of puberty blockers for gender dysphoria and enables their cost to be fully paid for by the National Health Service. The new president of Aifa, Professor Robert Giovanni Nisticò, said it was “necessary to tackle this sensitive issue with a rigorous and evidence-based scientific method.” Aifa is to work in consultation with the technical panel and the National Bioethics Committee (CBN). Professor Nisticò, a neuropharmacologist, cited the trend of other European nations to adopt more cautious treatment policies, as well as systematic reviews showing the weak and uncertain evidence base for hormonal interventions.

Italy’s multi-agency rethink follows a health ministry inspection of Florence’s Careggi hospital gender clinic, reportedly the main centre for puberty blockers in the country. The clinic was found to be giving puberty blockers to children as young as age 9-10 in breach of Aifa’s rules requiring psychological interventions and multidisciplinary assessment involving a neuropsychiatrist to determine any non-gender causes of distress. The Corriere Della Sera newspaper reported: “Psychotherapy was not given to the children who presented themselves before the psychologist, who instead asked them directly to establish their gender identity. That is, [the psychologist] would ask them directly how they perceived themselves, whether male or female. And then proceeded to administer the drug.”

The Public Prosecutor’s Office in Florence has opened a criminal investigation into puberty blocker treatment at the Careggi. There are reports that the hospital has suspended the use of puberty blockers. On May 15, however, Senator Maurizio Gasparri of the Forza Italia party—who had raised public concerns about rushed medical treatment last December—said it seemed the Careggi hospital was still giving puberty blockers to new patients. “If this is confirmed, it would be extremely serious. I have therefore submitted a new question to the Minister of Health to find out whether this is true and, if so, what further action the ministry intends to take to protect children’s health,” Senator Gasparri said. Aifa said the number of patients treated with puberty blockers in Italy’s regions last year was “about 25” and there had been no reports of adverse events in the use of the drug with minors. A medical writer who uses the pseudonym Agata Rossi says there are “private clinics offering puberty blockers to vulnerable children”, although “many Italian doctors, especially in the south, refused to prescribe puberty blockers to children and instead chose to take a less invasive therapeutic approach.”

Cover up

America | The World Professional Association for Transgender Health (WPATH), whose standards of care are cited by gender clinicians and public health authorities internationally as a guarantee of quality care, sought to restrict publication of a systematic evidence review which undermined the rationale for medicalised gender change of minors. This news emerged last week with the release of an email chain involving experts at Johns Hopkins University, which had been commissioned by WPATH to undertake multiple systematic reviews. On 31 August 2020, Professor Karen Robinson of the university’s Evidence-based Practice Center explained that WPATH was “trying to restrict our ability to publish”. She notes that after a systematic review “we found little to no evidence about [treatment of] children and adolescents”. In reply to her email, Dr Christine Chang of the US government’s Agency for Healthcare Research and Quality said it would be “disappointing” if the results of the systematic review were not to be generally available. “Knowing that there is little/no evidence about children and adolescents is helpful,” Dr Chang said.

Her agency is part of the US Department of Health and Human Services, which through its Office of Population Affairs published a March 2022 statement on “Gender-Affirming Care and Young People” claiming that, “Research demonstrates that gender-affirming care improves the mental health and overall well-being of gender diverse children and adolescents.” In September 2022, WPATH issued the 8th edition of its standards of care with a new chapter devoted to the fast-growing adolescent patient profile. It protested that “a systematic review regarding outcomes of treatment in adolescents is not possible [because] the number of studies is still low, and there are few outcome studies that follow youth into adulthood.” In a February 2023 investigation for the British Medical Journal, Jennifer Block reported serious concerns about the WPATH standards of care and the 2017 Endocrine Society guideline. She noted that WPATH had published only two of an undisclosed number of systematic reviews undertaken at its request by Johns Hopkins University. And she quoted two experts on evidence-based medicine, Professors Gordon Guyatt and Mark Helfand, as supporting the proposition “that a trustworthy guideline would be transparent about all commissioned systematic reviews: how many were done and what the results were.”

Video: A panel discusses the WPATH training materials unearthed by The Daily Caller

Doctor’s orders

Germany | The 128th German Medical Assembly has called on the country’s federal government to restrict puberty blockers, cross-sex hormones and trans surgery for minors to ethically controlled clinical trials with at least ten years’ follow-up. This runs counter to a new draft treatment guideline for German-speaking countries favouring liberal use of these medical interventions with minors. The assembly’s resolution, passed by majority earlier this month, sends “a strong political signal” and calls into question whether a new “gender-affirming” guideline will be adopted, according to the Munich child and adolescent psychiatrist Dr Alexander Korte, an expert on youth gender dysphoria who is an advocate for caution. Dr Korte told GCN there were other attacks on the draft guideline, including a letter from a parents’ group. However, he said the German Society for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy (DGKJP)—which with other specialist medical societies has presided over the guideline development project—was “proving to be very stubborn, stiff-necked and not open to scientific arguments.”

Dr Korte said the doctors’ resolution was not binding on government but would force a response from the German Medical Association (Bundesärztekammer), which is a central organisation in the country’s system of medical self-administration. The wording of the resolution says that trans hormones and surgery are “irreversible interventions in the human body in physiologically primarily health minors, who cannot give informed consent in the absence of evidence for such measures. Such interventions also influence the human psyche, especially in minors during their development. The use of interventions such as [puberty blockers or cross-sex hormones] is a form of experimental medicine on children, which is very likely to be followed by interventions in the child’s body, such as the amputation of the breast or penis, and which results in the loss of reproductive capacity and a reduction in the ability to experience sex, including anorgasmia.”

The doctors’ assembly also supported a resolution to amend Germany’s “self-ID” law so that the gender of a minor could not be changed legally “without prior specialist paediatric and adolescent psychiatric diagnosis and counselling.” Self-ID for children has been promoted internationally as distinct from their gender medicalisation. Dr Korte is among the critics who see self-ID as likely to increase this medicalisation.

Affirmative coercion

Chile | “‘In my daughter’s class, there are 22 students, and eight of them are now trans,’ says Alejandra, whose daughter was also self-diagnosed as trans at the age of 15, without having previously shown signs of what is clinically called ‘gender dysphoria’.” Media outlet El Ágora has profiled parents from the Chilean group Kairos (Agrupación Kairós), which formed last year out of concern at the phenomenon known as rapid-onset gender dysphoria (ROGD). More from El Ágora: “‘We families feel intimidated by the school system and the health system, which puts pressure on us so that the only way forward is the so-called ‘affirmative’ therapy,’ says Paulina, who notes that if you reject it, you are accused of being transphobic. I just wish there were more paths for my [12-year-old] daughter, because I am sure that a lot of the violence that we suffered with her father is behind her isolation and that today she is solving it with the trans issue, appearing in the world with a male figure, which is supposedly stronger’.”

Kairos—the name comes from the Greek word for an opportune time—brings together parents and professionals seeking to promote debate of an issue still little known in Chile. “Thanks to our publications on social media, we have been contacted by various mental health professionals from across the country, because they have been increasingly concerned about the growing cases [of ROGD] presented in their private practices,” a mother from the Kairos group told GCN. “At the end of 2023, we held a workshop day with therapists, featuring professionals who explained the ROGD phenomenon and testimonies from parents in our group, and we managed to organise a study group with ten therapists stemming from this workshop.” The mother said a lack of regulation was exploited by activist groups. “This has meant that any therapist can offer affirmative care to their clients, without having a proper qualification on the subject, since it is enough for them to declare it as a political-ideological position.”

Under the slogan “Chile grows with Pride”, the government promotes gender ideology and medicalisation. In partnership with Kairos, detransitioner Nicolás Raveau, who used to be a trans activist, has published research on the gender-affirming model and its impact in Chile. He says that despite a clinical pathway document restricting hormone treatment to those over 18, the public health system is promoting these interventions from the age of 14. “As far as private health care is concerned, there are prescriptions and medical records proving access to hormone therapy during the first consultation. There have even been unofficial reports of cases of Chilean children as young as 10 years of age being subjected to interventions with puberty blockers and hormone therapies, some of them with severe and permanent physical and psychological consequences.”