Shut down

The flagship gender clinic in Chile calls a halt to puberty blockers and hormones following intense media scrutiny

Photo by mauro mora on Unsplash

UPDATE, June 7 | Chile’s Health Minister Ximena Aguilera has reportedly ordered the public health system not to give puberty blockers or cross-sex hormones to any new patients.

The minister had acknowledged the weakness of the scientific evidence for paediatric gender medicine and the need to analyse England’s Cass report, according to Tele13 Radio journalist Paula Comandari.

During her June 6 broadcast, Ms Comandari said Minister Aguilera had decided “very discreetly, late on Tuesday,” to instruct the under-secretary for public health that no new patients be treated with blockers or hormones. Treatment of existing young patients would continue on a case-by-case. A statement confirming the policy shift would be issued within the next few days by the ministry.

“All this because the health minister [who by profession is a surgeon and public health specialist] has acknowledged that the scientific evidence is weak and that the information provided by the English report [of Dr Cass] should be analysed, even though the data has been circulating for several years now,” Ms Comandari said.

Ms Comandari, who touched on the controversy at England’s Tavistock gender clinic and the legal case of detransitioner Keira Bell, said the Cass report had triggered “an earthquake” in various parts of the world.

The effect of the Chilean health minister’s decision would be to mirror in the public sector the June 5 restriction imposed by the private UC Christus health network, where the country’s pioneering gender clinicians have been dispensing hormonal treatments to minors for more than a decade. 

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Original post, June 6

The most prominent gender clinic in Chile has reportedly suspended hormonal treatment of minors following the country’s first comprehensive media coverage of the troubling trans-affirmative medicalisation of minors.

The 13,500-word bombshell article “Interrupted puberty: transgender children start hormone treatment amid controversy” by journalist Sabine Drysdale was published on May 29 by BíoBíoChile, one of the country’s most popular news sites.

On June 5, the dean of medicine at the prestigious Pontifical Catholic University of Chile (UC), Dr Felipe Heusser, said the UC Christus health network had decided to suspend provision of puberty blockers and cross-sex hormones to new patients, according to Tele13 Radio journalist Paula Comandari. (GCN sought comment from publicists for UC Christus.)

In her broadcast, Ms Comandari said UC had been “in the eye of the hurricane” since BíoBío’s reportage. Follow-up media coverage, including an opinion article “Children in danger” in the conservative newspaper El Mercurio¹, has also picked up elements of the UC Christus story, framed by the international debate and England’s recent Cass report.

On May 31, opposition politician Dr Diego Schalper said he would press the health minister of Chile’s progressive-left government² for more information about the trans-affirmative support program Grow with Pride which has been extended to children from the age of three. Dr Schalper, a 39-year-old lawyer educated in Chile and Germany, also called for a special session of the Family Committee in the lower house of parliament, where he is a deputy.

“It seems to me that an issue like this should be approached very seriously, looking at the scientific evidence and international experience; and always with child protection as a guiding principle,” Dr Schalper, of the centre-right party National Renewal, said in a tweet on May 31.

Under the government of President Gabriel Boric, a former student activist, 1,202 children were given trans support (acompañamiento) in 2023 as part of the Grow with Pride program³, with another 2,940 expected this year, BíoBío reported. (The number going from social to medical transition is unknown.)

“This means that, in just two years, more than 4,000 children will have been seen, despite the lack of consensus in the medical-scientific community and the backlash in several European countries on applying treatments,” the BíoBío article says.

The parents’ group Kairós and Detrans Chile—both critical of the “gender-affirming” treatment approach and both with members featured in BíoBío’s coverage—welcomed the media breakthrough and the decision to suspend paediatric gender treatment at Santiago-based UC Christus.

“The gender issues are not part of the major political debate as of right now, and the importance that we see in this [BíoBío] article is that it has put these issues for the first time in the spotlight of public opinion and political debate,” a Kairós spokesperson told GCN.

In a joint statement, the two groups said UC should have acted sooner. They said parents whose children had received “hasty affirmative treatment” had put their concerns to UC Christus authorities more than a year ago, “without results.”

The groups said the 2020 UC Paediatrics manual—recommending “reversible” puberty blockers for children as young as age 9-10 at Tanner stage 2-3 of puberty—was out of date, cited no gender medicine studies since 2018, and UC Christus had ignored the post-2019 international policy shift away from poorly evidenced hormonal interventions in Finland, Sweden and England.

Against a background of local media neglecting⁴ the gender clinic story, Ms Drysdale’s BíoBío reportage includes—

stories of families affected by sudden opposite-sex identification of children

cases of desistance and detransition, as well as one family satisfied with puberty blockers

the role of trauma, autism, mental health problems, and unappealing gender roles— especially for girls sexually maturing—as causes of what presents as gender distress

the Ministry of Health mandating a gender-affirming treatment approach

education policy promoting social transition without parental approval

non-affirming parents being reported to a family court

government officials and gender clinicians pushing social and medical transition of minors ahead of the law, the weak evidence base and the uninformed state of public opinion

the country’s top gender clinicians advising puberty blockers for young children while admitting they have no long-term safety data.

Dr Cass and the Pope

One of those clinicians, endocrinologist Dr Alejandro Martínez of the UC Christus network, defended gender-affirming treatment on mental health grounds but conceded to Ms Drysdale that “we have to take the Cass report very seriously.”

After BíoBío published the article, UC Christus and its Catholic university backer issued a joint statement citing the April 12 Cass report as well as the April 8 Vatican denunciation of “gender theory” and “any sex-change intervention” as offensive to human dignity.

“[In light of these two influences], since April 12 of this year, we have been reviewing, evaluating and updating our practices and protocols for the care of transgender people in order to continue providing them with the appropriate, safe and welcoming support they deserve,” the joint statement says.

“The constant and dynamic evolution of medicine has recently generated scientific information, [namely, the Cass report] which puts a note of caution regarding hormone treatment for transgender children and adolescents.”

The joint statement made no reference to any suspension of puberty blockers or cross-sex hormones for new patients at UC Christus.

The BíoBío article highlighted the curious fact that the Catholic-backed UC Christus network was giving minors hormonal interventions that could sterilise them, but referred them to an outside clinic for fertility preservation because religious doctrine prohibited in-house infertility treatment.

The article also told the story of Andrés, a 15-year-old boy prescribed puberty blockers by UC Christus and told to freeze sperm to preserve his fertility⁵.

The boy’s father detected a “tremendous double standard”. At age 40, and content with three children, the father was refused a vasectomy by the same health network on the grounds that its policy was “not to alter the natural course of life, not to artificially induce something that alters reproduction.”

A spokesperson for the group Kairós told GCN that people were “very shocked that a conservative [health] network is promoting gender-related treatments, because they are well known for opposing abortion, vasectomies and other procedures that could go against Christian values.”

“[Andrés, a dreamy, somewhat melancholy boy who made a trans declaration at age 15], started to grow up, the pandemic ended, he went out with friends, he started to like girls, and he started to like being a boy. He lived the life of an ordinary teenager. As the treatment for depression began to work, the dysphoria dissipated. Towards the end of the [family therapy] sessions he told us, ‘This has to do with something else, with a more personal non-conformity’, because trans is a form of denying oneself, it’s like saying this is not me that you are looking at. What we did was to reinforce self-esteem very consciously, we encouraged critical thinking, we took down all the social media networks and we bonded very strongly as a family.”—the mother of Andrés, who is now 18 and has a girlfriend, as reported by Sabine Drysdale, BíoBío, 29 May 2024

Orwell in Chile

In his El Mercurio opinion piece, political scientist Dr Daniel Mansuy recounts the lessons of the Cass report and applies them to trans-affirmative medicine in Chile as reported by Ms Drysdale.

“This picture is aggravated if we consider that the government has resolutely pushed the affirmative [treatment] policy,” Dr Mansuy writes.

“The [2018] gender identity law allows children over 14 years of age to change their registered sex with the authorisation of a tribunal, in addition to receiving support in the process.

“However, the current administration reduced the age to receive counselling in this matter to... three years⁶. Moreover, when they cannot write, children sign with a dash (they cannot sign, but can consent!)

“A document from the Ministry of Social Development indicates that if parents oppose certain measures, they must be re-educated or denounced to the courts; and in fact, one parent is being sued for not accepting the ‘proposals’ of the officials. Orwell could not have said it better.”

Breasts that do ‘damage’

In her BíoBío reportage, Ms Drysdale profiles the advocacy foundation Together with You, run by Juan Carlos Tapia, and the only such private entity accredited by the government to deliver trans support.

Mr Tapia told Ms Drysdale his foundation had helped 653 trans-identified children.

Drysdale: Do you refer for mastectomies?

Tapia: Of course, and it is done in the adolescent stage, between 15 and 16 years of age.

Drysdale: [Such a patient] won’t be able to breastfeed if she wants to be a mother and she will lose all erogenous sensitivity.

Tapia: I would dare to say that a person who is in a process of transition, who has been supported by professionals for many years and whose family has been very well informed and is seeing that the boy’s breasts are causing tremendous damage, the best thing for this child is to have surgery.

Drysdale: At 15 years of age, she has the maturity, when the brain finishes its development at age 25?

Tapia: But how many adults are not mature?

Drysdale: At 15 she can’t drive, buy a cigarette, a beer or get married, but she can decide to cut off her breasts?

Tapia: It’s the parents who make the decisions for their children. Believe me, what you have just argued is very commonly said.

Mr Tapia makes the case that it is better for children to come to him young—between age 3 and 11—when they are “not yet so damaged” by their parents’ ignorance.

Tapia: It is the parents who have to acquire the tools to deal with the [transition] process and not the child who has to be in psychotherapy… Perceiving yourself as different from your genital sex is natural. Because the child has been trans all his life… What is causing the harm? Rejection. Parents are the first to cause emotional damage and insecurity to children.

Drysdale: And what did you study?

Tapia: I am a graphic designer and web programmer.

Ms Drysdale reports that Mr Tapia has provided training to 12 universities, 60 schools, nine municipalities, several hospitals, family health centres, the national police, the National Service for Minors, the Ministry of Education, and “even the Undersecretariat for Children itself, which accredits him.”

His journey started more than a decade ago when his own daughter told him she was trapped in the wrong body. “And as the saying goes, ‘if life gives you lemons...’,” Mr Tapia says.

We also meet midwife and academic María Isabel González, known as Mabe, who has been treating trans-identifying teens for 14 years. She gives Ms Drysdale “a technical talk on thoracic dysphoria” among girls who identify as boys.

Drysdale writes: [Mabe] opens her computer and on the screensaver, there is a Freddie Mercury face with a crown on his head, earrings in his ears and the caption: ‘God save the queer.’ She starts scrolling through the slides of her presentation. Crude illustrations appear. Hands digging their nails in and tearing their breasts to shreds.

Mabe: It’s the idea of physically and violently removing breasts.

Drysdale: Photos of homemade techniques include torsos forcibly bound with cloth, breasts bound with duct tape. She has also seen five fleece collars, one on top of the other, as a method of crushing breasts… Is there a certain self-hatred?

Mabe: Yes, there can also be self-harm to the breasts. The gynaecologists tell me about it. Here the only permanent solution is surgery, but we see barriers of age, institutional economic barriers, family support. In the public system, there are waiting lists that became more acute in the pandemic, and breast cancer has priority. But in the private sector there are teams that do not wait for the age of majority. It is done for emotional well-being. You are moved because you can empathise with their pain and suffering and all you want to do is facilitate their access to surgery, which is the only permanent solution when there is dysphoria.

Drysdale: Couldn’t this thoracic dysphoria be treated with psychotherapy, with medication?

Mabe: I’ll give you a crude example. Imagine if you had a penis, it would probably bother you, no matter how much you went to therapy.

Ms Drysdale also interviews two of the nation’s top gender clinicians—endocrinologist Dr Martínez from the UC Christus network and the Faculty of Medicine at the Catholic University, with his colleague Dr Carolina Mendoza, who was authorised to speak on behalf of the Chilean Society of Endocrinology. Dr Martínez says UC Christus has given hormonal treatment to about 200 minors over a decade.

Drysdale: Many of the children who present with gender incongruence are on the autistic spectrum [ASD]. Isn’t that a contraindication for treatment?

Martínez: People with ASD have every right to gender identity. They may have a much more structured, rigid way of thinking, which obliges their healthcare provider to find tools for them to be able to express their gender experience. You don’t question if an ASD patient says they are gender diverse, but for them to be able to communicate this, you need a lot of work with a psychologist, psychiatrist, occupational therapist. The other thing we face from an ethical point of view is that in order to get across the pro and con effects of medication, it is sometimes necessary to resort to other types of communication, things like drawings, so that the person can understand, within their capabilities, the progressive treatments they are undergoing.

Drysdale: And in cases of severe autism, with violent outbursts and other complex behaviours, is there no contraindication?

Martínez: This is a population that is stigmatised per se. We as a community need to have cultural humility towards people with ASD. As healthcare providers we have to develop a capacity to understand whether that person is going to benefit or not.

Drysdale: Who is contraindicated for treatment?

Mendoza: One of the indications to start any treatment is that the mental health team has assessed that person and can detect a contraindicating condition—for example, psychosis⁷. That person is out of touch with reality and has no capacity to decide.

Drysdale: But I have spoken to patients of yours and they have said they were not asked for any certificate from a psychiatrist or psychologist in order to start treatment with puberty blockers.

Martínez: We don’t ask for a psychiatric certificate that someone is trans, because doing so means making a diagnostic formulation and that is pathologising a condition that is part of human diversity.

Drysdale: If a healthy nine-year-old girl comes in at Tanner stage two [in early puberty] and starts with blockers and continues with cross-sex hormones, she will be a chronically ill patient for the rest of her life. The treatment you propose to alleviate one thing, makes them sick with another. They are left with bone problems, metabolic diseases, permanent urinary tract infections, and so on.

Martínez: All these things you tell us about, we monitor them every three to six months.

Drysdale: The motto of medicine is primum non nocere—first, do no harm.

Martínez: Is it the doctor who has to assume the risks, or is it the person who is going to be exposed to those risks? We don’t force anyone here. In every consultation you create the opportunity, and you tell them that, ‘I will also be your doctor if you want to detransition, I will support you in that.’ This patient who is trans has more medical risks, undoubtedly, and we as doctors recognise that, and that is why we try not to keep them away from medicine, but to support (acompañar) them. But choosing between exposing them to chronic conditions and their mental health, the most important thing is that this person manages to sustain over time the mental health that allows them to have a life project.

Drysdale: The benefit is mental health, then. That is the relief.

Martínez: It’s impossible for a cis-gender⁸ person to have an opinion on this. You will never understand what a trans person feels.

Drysdale: Excuse me, you’re cis gender?

Martínez: Yes.

Drysdale: Do you have no ethical qualms about turning a healthy child into a sick child?

Martínez: I think the concept of illness that you are arguing for does not understand the experience of a trans person. And you don’t understand it because you are cis gender and your culture is very cis normative. It is much easier when you have seen the suffering of these families. I have spent ten years seeing how these patients suffer and looking for the best alternatives to prevent that suffering from continuing over time and, within our medical capacities, which are also limited, with costs and benefits, among all those risks, we take the option that, above all, allows us to keep a person alive.

Mendoza: We are talking about life or death. Patients commit suicide. If you look at the statistics, trans people have up to 40 per cent suicidal ideation at some point in their lives and that’s four times more than the general population.

Drysdale: Does that stop with treatment?

Mendoza: It decreases.

Martínez: But it doesn’t necessarily stop.

Mendoza: I think it is less ethical to leave a person without an intervention they are seeking and isolate them from the health system by putting up more barriers, rather than to support them in a safe way.

Drysdale: Do you know what effect puberty blockers have on children’s cognitive development?

Mendoza: No, not yet.

Drysdale: No long-term studies, aren’t you experimenting on children in real time?

Martínez: On the neurocognitive side there is evidence in animal models, but little in humans because it is much more complex. But on the other hand, it is not neutral not to treat, because the patient, being under stress, will change the neurocognitive part more.

Drysdale: The president of the World Professional Association for Transgender Health, the affirmative doctor Marci Bowers, who is also transgender, admitted that a boy who is blocked at Tanner stage two, at the onset of puberty, will never experience an orgasm or have sexual functionality in adulthood. What happens to a human being when that dimension of their life is cancelled out?

Martínez: In the work we do, psychosexuality improves, because untreated trans people don’t want to wash themselves.

Drysdale: What does that have to do with the ability to have an orgasm?

Martínez: They don’t touch themselves, they don’t masturbate, they don’t want the person they are in love with to see them, they avoid kissing. There is less physical contact in those who are untreated. And the treated ones improve in all those aspects of psychosexuality.

Drysdale: When you use blockers, the penis remains very small.

Martínez: Yes.

Drysdale: Does it allow them in the future to have full sexuality?

Martínez: I warn them that if they go into [puberty blocker] treatment so young their testicles will be frozen and also their phallus—because we never say ‘penis’ for a trans girl, because it is super aggressive: you are telling a woman that she has a penis. So, you explain to her, your phallus is not going to grow, it’s going to be tiny, that’s going to make reconstruction surgery [for an artificial vagina] more difficult, and despite all that, they still want early intervention [with puberty blockers] to avoid [secondary sex characteristics such as] the Adam’s apple, the [the male] jawbone, the voice. At the moment, rather than forcing the patient to face a challenge, the challenge is for medicine and how it is going to create a neo-vagina in a patient who has little foreskin.

Drysdale: The Cass report is very critical of trans-affirmative health in children.

Mendoza: The affirmative approach is what is recommended by all medical societies today.

Drysdale: Do you plan to make changes?

Martínez: We are discussing them. Who do you think [Chile’s] paediatric society and the endocrinological society called to discuss the Cass report? Us. We are not rigid or dogmatic. [The report] forces us to analyse, reflect and see what we can change, but we also recognise that the Cass report might have shortcomings. When I started in this, there were ten-year-old children who had tried to commit suicide twice because they were depressed, distressed, stigmatised. But in this decade, we have made progress and that has allowed people to end up not so damaged. Perhaps it will no longer be so easy to prove that there is so much benefit in stopping puberty because socially [these trans-identifying minors] are more accepted. But we have to be cautious, and we have to take the Cass report very seriously.

1. BíoBío also ran an opinion piece in reply to Ms Drysdale’s reportage by a trans activist academic Andrés Ignacio Rivera Duarte. He acknowledged the Cass report had “found that there is insufficient evidence of the benefits and risks of using hormones and puberty blockers” but dismissed Dr Cass as “a paediatrician giving her biased opinion, who doesn’t know the suffering of families, who doesn’t even know a trans body torn with cuts and self-harm.” During her review Dr Cass did meet trans advocacy groups and families who wanted hormonal interventions to continue as routine treatment.

2. Chile’s government and health professional societies have remained silent on the Cass report.

3. Ms Drysdale told GCN she was struck by the contrast between the celebratory promotion of a program such as Grow with Pride and the suffering involved: the hormonal treatment that creates permanent patients perhaps with no sex life as adults. “I don’t think there’s a happy ending to all this. Yes, maybe some people will feel happier than before, but there’s still a lot of suffering in the whole process. It makes me think, how weird that this [trans issue] that has a lot of suffering, is presented in a way like it’s fun or colourful.”

4. Ms Drysdale said the reality of paediatric gender medicine—practised for more than 10 years in Chile without, it seems, attracting any serious media curiosity—had come as a total surprise. “I am a very well-informed journalist, and I knew nothing about it. So, most parents knew nothing either.” She said BíoBío had a reputation for independent and fearless reporting, so she did not have to contend with woke editors. She had noticed the gender clinic debate in US and UK media. During her research, she asked a specialist in psychiatry and neurology about the effect on the brain of puberty blockers. “I learned that, of course, nobody knows, because there are no long-term studies.” She also discovered that gender medicine was news to this specialist too; he reacted as if “I was talking Chinese” when describing these hormonal treatments. She said she had no personal stake in the controversy. “I am an old-school journalist, I work for the story. I don’t care if it’s from the right wing or left wing.” Ordinary people in her social circle were very surprised by the revelations in her article. Ms Drysdale is also known in Chile as the author of the book The Private Lives of Men, a personal inquiry into less talked about aspects of being male.

5. The parents of Andrés discovered, thanks to Abigail Shrier’s book Irreversible Damage: The Transgender Craze Seducing Our Daughters, that the vast majority of children begun on puberty blockers went on to cross-sex hormones supposed to be taken lifelong. “In other words,” the mother said, “it was a one-way ticket, with no return and we said no!”

6. Ms Drysdale thought it would be worth approaching the senators and deputies of Chile’s parliament responsible for the 2018 law enabling minors to change their official sex and ask them if they would have voted for it had they known its unexpectedly radical consequences.

7. The 2018 “Australian standards of care” treatment guideline issued by the Royal Children’s Hospital Melbourne advises that psychosis in a child is no necessary barrier to medical transition.

8. “Cis” is a gender theory term for someone who does not identify as trans.