Not in our name

Dutch goalposts on the move; common sense of an Aussie gender clinician; tips for Trump; Italian prof calls out research taboos; talking self-harm with Wes Streeting; laying down the law in Chile

Photo by Morgan Bryan on Unsplash

GCN in brief

No, minister

France | The French newspaper Le Point has published an open letter from cautious clinicians and researchers protesting against a draft “gender-affirming” guideline that would allow minors from the age of 16 to be given the same swift access to gender medicine as adults.

The letter “Not in our name,” organised by the watchdog group The Little Mermaid, says the guideline position adopted by the French National Authority for Health (La Haute Autorité de Santé, HAS) is “almost identical to that of the trans-activist associations” and includes recommendations “even more radical” than those of the scandal-plagued World Professional Association for Transgender Health (WPATH).

The draft HAS guideline was revealed last month by the newspaper Figaro, prompting a media statement from the HAS deploring the publication of what it said was a “confidential working document” to be finalised in the first half of this year.

The Little Mermaid letter of protest has been sent to the HAS and the new Health Minister, cardiologist Dr Yannick Neuder. He belongs to the centre-right Republican party which drew on the expertise of the Little Mermaid co-founders—clinical psychologist Dr Céline Masson and child psychiatrist Dr Caroline Eliacheff—to produce a historic report to the Senate last year on the risks of gender medicine for minors.

The open letter circulated by the Little Mermaid says—

“Young people aged 16-18 should not be considered as adults, even though they are neither legally nor psychologically adults. In the light of current studies, the mutilation of healthy organs should be banned for minors. Their suffering, which is very real, must be addressed by other means. The HAS not only authorises [mastectomies], but also extends the authorisation to surgery on the genital tract, which until now has not been performed in France before the age of 18.”

The letter also objects to provisions in the draft HAS guideline empowering trans-activist lobbies against parents who resist medicalisation.

“Parents of minors must not be threatened with withdrawal of parental authority if they oppose their child’s wish to undergo medical and/or surgical transition. ‘Feelings’ may be expressed, but their realisation is not a right,” the letter says.

“Under no circumstances should [trans-activist] associations encouraging gender transition in adolescents take the place of the public prosecutor’s office in encouraging prosecutions, as there is a major risk of sectarian hold over adolescents.”

Switcheroo

The Netherlands | Researchers at the Amsterdam clinic associated with the “Dutch protocol” of puberty blocker-driven gender change for minors have in effect acknowledged the weakness of the claims of benefit that inspired international adoption of the protocol.

In a new paper published in the journal BMC Medical Ethics, psychiatrist Dr Annelou de Vries and colleagues admit the weight of growing scrutiny of the low-quality evidence base and doubts about the capacity of minors to consent to treatment with risks of infertility, detransition and regret.

However, the researchers deploy the Queer theory concept of “trans negativity” to imply that the very idea of gender medicine having to reduce gender dysphoria and improve psychological functioning is a “normative” imposition by an oppressive society, rather than a claim of the gender-affirming model itself.

They flirt with a totally subjective justification for these hormonal interventions: the “desire” of the under-age patient and not beneficial treatment outcomes. Here, they cite the US writer Andrea Long Chu, a trans-identified male, who declared in The New York Times in 2018 that, “My new vagina won’t make me happy and it shouldn’t have to.”

The paper by Dr de Vries and colleagues is at pains to fend off any “gatekeeping” by clinicians, preserve access of minors to “gender-affirming care” and defuse the complaints of critics.

It notes, for example, that gender clinic sceptics “express concerns that suppressing puberty may even negatively affect psychological functioning.” This is waved away with the remark that “the ambiguity surrounding the ‘effectiveness’ of [early medical intervention for] adolescents stresses the complexity of this care practice.”

Some other statements characteristic of the paper—

“[T]ypical evidence-based medicine practices (i.e., relying on scientific evidence and clinical expertise) may not always help to inform decision-making in this context [of whether gender medicalisation should be allowed during the critical development period of youth].

“Trans negativity challenges the dominant discourse that [medical treatment] must necessarily alleviate distress and lead to improvement in overall wellbeing and functioning in order to be justified, instead acknowledging that negative feelings often persist after, or even because of, [treatment].

“[R]esearch that concludes anything less than unequivocal ‘effectiveness’ of [treatment] risks providing critics of this care practice with ‘ammunition to attack trans medical care’.”

The new Dutch paper has generated much criticism, including a tweet by UK author JK Rowling—“This astounding paper reminds me of Hannah Arendt’s The Banality of Evil: ‘The net effect of this language system was not to keep these people ignorant of what they were doing, but to prevent them from equating it with their old, ‘normal’ knowledge’.”

In the Netherlands, Health Minister Fleur Agema faces a series of questions about the implications of the paper from MP Diederik van Dijk, whose successful parliamentary motion last year set up an independent Health Council inquiry this year into the medico-legal implications of medicalised gender change for minors.

Mr van Dijk’s questions include—

“What do you [as health minister] think of the possibility raised in the [de Vries] article that, analogous to abortion or contraception, for example, gender treatment of minors could be viewed and justified based on personal desire and autonomy?

“Do you recognise that such an approach based on the personal wishes and autonomy of a child is risky, given the irreversibility of certain medical gender treatments, the uncertainty about long-term effects and the prevention of transition regret?

“Could you please explain what criteria and/or standards medical gender treatments on minors are currently tested against in terms of effectiveness and appropriate care?

“Can you indicate what the consequences will be, for example for reimbursement under the Health Insurance Act, if medical gender treatments for children turn out not to meet these standards?”

Common sense

Australia | A Family Court judge in Australia has resolved a dispute between parents by approving testosterone for their 16-year-old trans-identifying daughter.

In his November 2024 decision published last week, Justice Tree says he gave “little weight” to England’s Cass report, placing it in a “political” context in which “there is considerable outcry about many issues surrounding transgender people, including to the point of challenging them and their authenticity altogether.”¹

The judge cited an October 2023 remark by the then UK Conservative prime minister Rishi Sunak that “we shouldn’t be bullied into believing that people can be any sex they want to be” as a hint of “an overt political imperative behind the Cass review.” In fact, Dr Cass’s review, which began in 2020, has enjoyed bipartisan support in the UK; the current Labour government imposed an indefinite ban on puberty blockers.

Justice Tree said that some people might regard his ruling in re Ash “as a judicial foray into politics, but it most definitely is not.”

He accepted wholesale the testimony of an unnamed Australian psychiatrist and gender clinician, known as Dr O, who “explained the usefulness of low-quality studies” favouring hormonal treatment of minors and held up the World Professional Association for Transgender Health (WPATH) as a source of “authoritative guidance.”

The judge notes Dr O’s complaint that Dr Cass “has absolutely no experience in the provision of care to transgender adolescents” but he regards Dr O’s involvement in a gender clinic and a gender-affirming guideline as hallmarks of expertise, rather than a conflict of interest.²

Justice Tree says it is likely that testosterone will give the teenager, known as Ash, at least some short-term relief from gender dysphoria. He was satisfied that Ash understood the risks including infertility and regret.

Asked at trial whether adolescents “can give a falsely exaggerated impression of capacity” to give informed consent Dr O disagreed, claiming the science showed that “most 16- to 18-year-olds have good, functioning brains.” Dr O said competence to consent did not guarantee against regret, but Ash had the right to be afforded the “dignity of risk.”

The judge says the lawyers for the parent opposing testosterone had tried to run “a royal commission” and use the case to “subvert” the gender-affirming treatment policy of the state government responsible for the clinic that diagnosed Ash and the positions adopted by medical professional bodies.³

He protests that the courts, and in particular a family law court, are “the bluntest of instruments when it comes to choosing between competing bodies of opinion within the medical and allied professions.”

“Who am I, without medical training or clinical experience whatsoever, to disagree [with a claimed consensus favouring gender medicine]?”

Even so, Justice Tree declares it is “just common sense” to agree with Dr O that WPATH offers “the best available guidance”—scandals affecting its credibility go unmentioned—and that strong treatment recommendations can rest on low-quality evidence “in some situations.”⁴

Dr O’s testimony falsely implied that the Cass review disregarded the evidence of studies that fell below the high-quality grading, a level which Dr O said would demand difficult-to-run and unethical randomised controlled trials (RCTs).

“There are even fewer well-conducted RCTs in paediatric medicine than there are in adult medicine,” Dr O said. “It is, therefore, not valid to discard the whole field of gender-affirming health care because there are no RCTs.”⁵

Justice Tree describes Dr O as “a commanding witness” and “a formidably qualified child psychiatrist with vast experience in transgender health, and considerable experience beyond that area as well, including significantly, in psychotherapy.”

Dr O implied that promotion of psychotherapy for gender distress could be “dangerous” and a “covert exercise” in seeking to change a child’s “gender identity,” saying—

“[Psychotherapy is expensive] in time and money and potentially emotional cost. It’s great if there’s something to talk about. But if it’s a healthy young person who just wants to not grow breasts, so he can keep playing footy in his boys’ team, as he always has, because he feels he is a boy and has always been a boy … at age 11, you know, talking with [a psychotherapist] about how the earliest breast budding is causing him great difficulty, and he has been living as a boy since he was six, because that’s how he feels, telling that person to go sit and talk about it once a week for two years until his breasts are formed doesn’t go down well.”

A paediatrician, Dr E, who gave evidence for the parent opposing testosterone, noted the wish of Ash to be perceived and treated as male, and said there was “little exploration of what this means to [Ash], nor is it indicated that [Ash] has been told, and fully understands, that she will always be female, even if she has a masculinised outward appearance.”

Dr O condemned the paediatrician for appearing “to advocate a harshly confrontational approach to talking with an adolescent about their gender identity and future wishes.”

Justice Tree also rejected a suggestion that Ash’s expectations should have been “reality tested” because the teenager had expressed the desire for “bottom surgery”—radical genital surgery, with high rates of complications, to create a pseudo penis.

It was put to the judge that Ash should have been told this genital surgery was “expensive, carries significant risks, and is hard to source.” This was said to be relevant to “whether Ash understood that [testosterone treatment] might be as far as he can go, and hence might not want [testosterone] at all, if his final ultimate goal is unattainable.”

But the judge said: “I do not accept that discussing other potential later interventions, which although desired by Ash, might not be possible, was critical to him adequately understanding the risks of testosterone.”

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Shine a light

America | Incoming US President Donald Trump should direct the National Institutes of Health (NIH) to disclose the suppressed puberty blocker data from its $9.7 million study led by high-profile gender clinician Dr Johanna Olson-Kennedy, according to a National Review article by Drs Stanley Goldfarb and Roy Eappen of the group Do No Harm.

In October last year, The New York Times reported that Dr Olson-Kennedy had withheld data showing no improvement after puberty blockers because she feared it could be “weaponised” and used in litigation by opponents of gender-affirming care.

Drs Goldfarb and Eappen say the Olson-Kennedy study “violates NIH’s requirement that the research it funds must be ‘free from bias resulting from an investigator’s financial conflict of interest.’ Olson-Kennedy provides puberty blockers and other treatments at her practice, as do at least three of her co-researchers. They have a vested interest in seeing their own business model validated.”

The Do No Harm doctors also urge the Trump administration to order the US Department of Health and Human Services to undertake a systematic review of the evidence base for youth gender medicine.

Cass lifts the bar

United Kingdom | The decision by a general practitioner (GP) in Brighton, England, to prescribe cross-sex hormones to a 16-year-old trans-identifying boy has been challenged as unlawful because it was allegedly contrary to the new “extremely cautious” approach advised by the Cass report.

The prescribing was done “without any diagnostic process compatible with the Cass report nor NHS England’s clinical commissioning policies,” according to High Court documents in the judicial review filed on behalf of the father of the boy.

“In October [2024], we found out that [GP] Dr Sam Hall of WellBN [clinic] had issued a prescription for powerful medication blocking male testosterone and adding female oestrogen, which impacts on brain development, fertility, and sexual function,” the father told The Daily Telegraph.

In response to the Cass report, NHS England undertook to review the use of cross-sex hormones for gender-distressed minors.

A risky taboo

Italy | An April 2024 expert report to a parliamentary committee in Italy by psychologist Professor Marco Del Giudice, recently republished by Italian parents’ group GenerAzioneD, has advised that new treatment guidelines for gender dysphoria in minors should encourage clinicians to consider alternatives to the gender-affirming approach.

Professor Del Giudice says—

“In the absence of solid evidence that the benefits of affirmative treatments outweigh the risks, it is prudent and reasonable to consider restrictions on their application, especially in the case of underage patients and invasive interventions (including puberty suppression, which is performed at a particularly critical time for physical and psychological development and almost always routes adolescents into medical transition).

“These treatments could be allowed within the framework of experimental protocols with well-defined criteria, allowing useful data to be collected in a systematic and centralised form, with appropriate control procedures, randomisation, and long-term follow-up. Without quality data, there will be nothing to be done but to continue to muddle along; this would be a grave disservice to patients and their families.”

Professor Del Giudice, from the University of Trieste, says “real ideological taboos” discourage research in this field.

He cites a 2022 study by Mirabella et al in which 42.5 per cent of males and 52.4 per cent of females in a group of patients at gender clinics in Rome and Florence identified social media as a determining factor influencing their gender identity. Knowing other trans people was also stated as an influence.

“These data are clearly open to multiple interpretations, including the one that social transmission and contagion processes play a role in transgender identification,” Professor Del Giudice says. “However, it is noteworthy that this hypothesis was not even considered by the authors of the study...”

Lived experience

United Kingdom | The UK Labor Health Secretary Wes Streeting and aides met a small group of trans-identified teenagers and their parents in October before he imposed an indefinite ban on puberty blockers for gender-distressed minors, according to a news report in Metro this month.

Hannah, one of the mothers, told Metro that the teens were “begging [Mr Streeting] not to ban puberty blockers because [lack of access to these drugs] was harming them.” She said Mr Streeting had asked the group to be as “brutal” as they could in expressing their views and told them he understood their plight.

“He’s gay and had difficulty coming to terms with that as a child, so he wanted to do the right thing for these kids,” Hannah said. However, she said, “Even when the kids were talking about self-harm and suicide, there was just no reaction on his face at all. He’s a politician and maybe that’s how he’s trained to react.”

Wrong side of the law

Chile | Gender-affirming medical treatment of minors, exposing them to sterilisation, is happening in Chile in defiance of law and bioethical principle, according to a new paper in the Chilean Journal of Law by Professor Alejandra Zúñiga-Fajuri of the Autonomous University of Madrid and the University of Valparaíso.

Her paper focuses on Chile’s laws on mental health, patient rights and research which, while recognising the “right to progressive autonomy” of children and adolescents as they mature, also “maintains the exercise of informed consent by their parents or legal guardians and makes illegal, even with their authorisation, any procedure involving their sterilisation.”

Those laws, Professor Zúñiga-Fajuri says, “contain provisions that support scientific evidence showing that the young brain is biologically and socially immature, tends to take short-term risks, lacks the capacity to understand likely future consequences, and is overly responsive to the influence of peers.”

“Thus, initiating gender transition processes in minors… is in defiance of existing law on legal capacity, rules on informed consent in the context of scientific research, and the best interests of the child… [A] blanket policy that simply affirms dysphoria as a primary condition is dangerous and untherapeutic,” she says.

“The tendency to affirm rather than further examine the child’s mental illness not only harms the child, but is a policy that violates the child’s right to quality healthcare and casts serious doubt on the physician’s ability to assess the patient’s competence and decision-making capacity—even more so, when the Cass report showed that, in most cases of dysphoria, these are children with significant psychological and social problems, and that the gender disorder tends to be secondary and transient.

“[The affirmative] model, instead of providing certainty about the patient’s capacity [to consent], promotes dispensing with any analysis of competence. Instead of demanding a clear diagnosis of the disorder, it rejects it in order to ‘depathologise’ dysphoria. Instead of giving reasonable guarantees about the safety of treatments and informing, with scientific evidence, about their consequences in the medium and long term, it ignores them.

“Medical professionals, when working with minors, would be expected to comply with informed consent laws in a more—not less—demanding way.

“In the face of an irreversible and experimental procedure, doctors should not make vulnerable children and adolescents bear the consequences of their choices under the fantasy that they ‘know who they are,’ ignoring all the evidence that exists on identity formation as an ongoing process during childhood and adolescence, and, above all, ignoring the law in force.”

Ban blockers

New Zealand | Emeritus Professor of Epidemiology Charlotte Paul has argued for a prohibition on routine use of puberty blockers for gender distress in New Zealand. In her judgment, a “rights-based” approach has trumped an “evidence-based best-interests approach” and gender medicalisation of minors is in breach of Medical Council standards, she writes in The New Zealand Herald.

She notes that the NZ regulator, Medsafe, does not approve the use of blockers for suppressing normally timed puberty, a novel usage for which there is no high-quality evidence base.

“There has been inappropriate reassurance about this ‘off-label’ use,” Professor Paul says. “It is not the same as using a medicine, approved for the same condition in adults, for children. In this case it is for a different condition. Similarly, extrapolating from studies of [the approved] use for precocious puberty is misleading.”

1. The names of expert witnesses, and even the lawyers who argued the case in open court, were suppressed by the judge. So, too, were unusual details of the case which would seem relevant to public understanding of Ash, with the judge citing the risk of the family being identifiable.

2. The fact that Dr Cass had not been implicated in the gender medicine debate was arguably part of the justification for appointing her as an independent reviewer. She was assisted by a clinical expert group, which included expertise “on children and adolescents in relation to gender, development, physical and mental health, safeguarding and endocrinology.”

3. The international and local gender-affirming guidelines used by the state government gender clinic were rated as poor quality and not fit for purpose by a peer-reviewed evaluation commissioned by the Cass review, which said circular referencing gave a false appearance of consensus. This is not mentioned in Justice Tree’s decision. The Family Court has itself endorsed one of these low-quality guidelines.

4. A 2023 investigation by the British Medical Journal scrutinised the guidelines from WPATH and the Endocrine Society. Professor Gordon Guyatt, who co-developed the GRADE system for rating the quality of evidence, noted “that the Endocrine Society had at times paired strong recommendations—phrased as ‘we recommend’—with weak evidence. In the adolescent section, the weaker phrasing ‘we suggest’ is used for pubertal hormone suppression when children ‘first exhibit physical changes of puberty’; however, the stronger phrasing is used to ‘recommend’ GnRHa [puberty blocker] treatment,” the BMJ reported. “‘GRADE discourages strong recommendations with low or very low-quality evidence except under very specific circumstances,’ Guyatt told The BMJ. Those exceptions are ‘very few and far between,’ and when used in guidance, their rationale should be made explicit, Guyatt said.”

5. The Cass review posted an FAQs page to counter misinformation, pointing out that studies in the moderate-quality category of cohort research were eligible for evaluation. But Dr Cass said even these gender medicine studies turned out to be “really, really weak”—even by the low standards of mental health research—with multiple methodological shortcomings. Swedish researchers have suggested solutions to the difficulty of RCTs.