The war over puberty blockers
Saturday, 28 September 2024
On a cold Monday in early May, Destiny Church leader Brian Tamaki was creating an uproar on one of Christchurch’s four avenues. The target was Te Tahi Youth, a youth health centre on Bealey Ave.
Tamaki had called for a protest outside Te Tahi Youth during a service less than 24 hours earlier. It was dubbed a pop-up protest. Even with the short notice, around 40 Destiny followers turned up and were waiting for their leader to arrive.
Some counter-protesters were gathered nearby in nervous opposition. Te Tahi Youth staff took the rare step of locking the gate in case there was trouble and a group of police officers kept a wary eye on things.
When Tamaki appeared with a small entourage, he delivered a rambling speech about the alleged dangers of puberty blockers. They are medicines used in the treatment of young people with gender dysphoria, when gender identity does not align with biological sex.
Tamaki singled out Te Tahi Youth and its patron, Dame Sue Bagshaw. The rhetoric turned bizarre. He called Te Tahi Youth “a tinny house” and said that Bagshaw, who he repeatedly misidentified as “Bagworth”, is “a female version of Pablo Escobar”.
The counter-protesters wore rainbow flags and held up signs saying “Protect trans youth”. They fired back at Tamaki and his followers.
“Jesus isn’t about hate!” one shouted. “Hate speech!” yelled another.
Still, Tamaki’s speech went on. The protest was part of what he called his “Christchurch clean-up”, which also identified the social threat of rainbow crossings.
“We’ve shut the drag queens down,” he said, referring to his organised opposition to drag queens reading to children in libraries. “We’re going to shut the blockers down as well.”
A chant started: “No more puberty blockers.” A few passing drivers tooted and waved.
The mood was tense but only threatened to turn violent when two burly Destiny followers tried to force their way through the crowd of Te Tahi Youth supporters before police redirected them.
Then Tamaki jumped into a waiting car, flashed a peace sign at his followers and the media, and sped away.
The ‘toxic’ trans debate
The uproar on Bealey Ave was a perfect illustration of a point made less than a month earlier by UK paediatrician Hilary Cass.
Cass wrote: “There are few other areas of healthcare where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour. This must stop.”
Those words appeared in her major report on transgender healthcare, known as the Cass Review. She also used the word “toxic”. Despite that message, her review further emboldened outspoken critics of the transgender cause.
UK magazine Spiked called the Cass Review “a devastating blow to trans ideology”. Journalist Julie Burchill in the UK’s Spectator claimed it exposed “the trans mob” as “liars, fantasists and bullies”. Author JK Rowling posted on X that the bandwagon trans activists “hopped on so gladly is hurtling towards a cliff”.
In fact, Cass wrote that her review “is not about defining what it means to be trans, nor is it about undermining the validity of trans identities, challenging the right of people to express themselves, or rolling back on people’s rights to healthcare”.
Emeritus professor Charlotte Paul of Otago University is New Zealand’s most prominent medical supporter of the Cass Review, and she is sceptical about puberty blockers, but she agrees it is “a mistake” to say the review undermines the entire transgender cause.
“The Cass Review does not undermine the right to respect and legal protections for people living as transgender,” she says in an email interview.
Instead it is a review of how the UK’s National Health Service (NHS) should treat young people experiencing gender dysphoria, which is an area that has been beset by controversy.
The Gender Identity Development Service (GIDS) clinic in London closed in March following serious issues that included a lawsuit brought by the mother of a former patient.
The NHS has also restricted puberty blockers to clinical trials for those under 18. Cass advised that “because puberty blockers only have clearly defined benefits in quite narrow circumstances, and because of the potential risks to neurocognitive development, psychosexual development and longer-term bone health, they should only be offered under a research protocol”.
But in an interview with the UK’s Kite Trust, which supports LGBTQ+ young people, Cass emphasised that puberty blockers are “not an unsafe treatment”.
Cass wrote that she spoke to transgender adults who are leading positive and successful lives, and who felt empowered by their decision to transition. She also spoke to others who have detransitioned, and who regret their earlier decisions.
Studies tend to show that between 1% and 3% detransition.
In New Zealand, the Professional Association of Trans Healthcare Aotearoa (Patha) sees puberty blockers as a useful way for young people with gender dysphoria to buy time. Puberty’s physical changes are paused while further gender-affirming care, such as hormone treatment, can be considered.
Puberty blockers were developed to treat what is known as precocious puberty, or when puberty begins too early for a range of reasons.
Their first use as treatment for gender dysphoria was in the Netherlands. Cass noted that they were trialled in the UK in 2011 and despite what she calls “a lack of any positive measurable outcomes”, they quickly moved from a research-only treatment to being more routinely available.
Critics say the use of puberty blockers has raced ahead of the evidence. Cass wrote that it is “an area of remarkably weak evidence, and yet results of studies are exaggerated or misrepresented by people on all sides of the debate to support their viewpoint”.
She added that we do not have enough “good evidence on the long-term outcomes of interventions to manage gender related distress”.
In New Zealand, Paul agrees with Cass and says that “in the absence of sufficient evidence of safety and effectiveness, use of puberty blockers should be confined to research settings. This will finally allow the evidence to be collected.”
How widely used are puberty blockers in NZ?
Chief Medical Officer Joe Bourne says the most reliable data shows that “387 young people between the ages of 12 and 17 were given the medicines leuprorelin and goserelin (which can be used to delay the onset of puberty) in 2023. Of these, 127 were prescribed these medicines for the first time.”
And how does this compare to other countries? Bourne says “a detailed comparison with other countries is not possible due to variability in data collection methods”.
But Paul and co-authors Simon Tegg and Sarah Donovan argue that New Zealand numbers have been higher than in other countries, according to data they published this week in the New Zealand Medical Journal. Between 2009 and 2018, use was 1.6 times higher in New Zealand than in the Netherlands, and 5.7 times higher or possibly 3.5 times higher than in England and Wales between 2008 and 2020.
An often-repeated claim that New Zealand rates are 10 times higher than the UK seems to have come from a massive drop-off in the UK after 2020, following a judicial review.
They add that Australia has no national data, and US data is hard to estimate as it does not include patients not covered by insurance.
One thing the New Zealand data can say more definitively is that puberty blockers numbers have fallen since 2022, but Paul and her co-authors can only speculate about why. They “tentatively suggest” it mirrors more cautious approaches by clinicians and parents.
There are other unknowns. When they consider why rates have been higher here than in the UK, they suggest access is easier, diagnostic criteria have been lower and puberty blockers are recommended more readily.
But the UK’s long wait times and restricted access make direct comparisons difficult. In fact, one of Cass’ recommendations is that the UK move to a less centralised model, which New Zealand already has.
That is one reason why the Cass Review has not been readily accepted in New Zealand, where Patha endorsed a message released by Equality Australia, which said: “England’s Cass review ignores the consensus of major medical bodies around the world and lacks relevance within an Australian context, say medical practitioners, trans advocates, parents and human rights groups.”
Uncertain evidence
Brian Tamaki had a secondary target on that day in Christchurch. He moved seamlessly from Bagshaw to the Government’s Associate Minister of Health with responsibility for the rainbow community, Matt Doocey.
Tamaki called Doocey a “weasel” and reminded his followers that Doocey once worked for London’s Tavistock Centre, which ran the controversial GIDS.
Doocey told Newstalk ZB in April that while he worked at Tavistock he had “no involvement with that service”.
But Tamaki’s reference to Doocey signalled another dimension of the puberty blockers story, which is that New Zealand has been waiting for updated official advice. There should be an evidence brief followed by a position statement that “will explain the ministry’s position on the use of puberty blockers going forward, in light of the evidence brief’s findings and an examination of settings in other countries,” Bourne says.
“The position statement will be appropriate for the New Zealand context.”
But where is it? The waiting has reached almost farcical levels. Reports were expected in April and then in August. The latest update is that “we are taking the time needed to ensure the most up-to-date advice has been considered, including the significant new publications internationally,” according to a spokesperson for Doocey.
What does Charlotte Paul want to see?
“I hope the ministry will announce the commission of an independent review,” she says. “This need not take four years like the Cass Review, but can build on that. In the meantime, I hope the ministry will make recommendations for holistic care for these troubled children, including mental health care, as Cass recommends.”
Yet she believes it is not possible to talk about treatments for gender dysphoria without “considering the reasons for the growing number of people, especially girls, with this condition”. In other words, the larger context and potential causes.
She calls it a wider societal issue and says “the role of schools and the internet are among the societal issues that will need to be considered”.
That suggests a more conservative view of gender dysphoria than the one held by Sue Bagshaw and others in the trans healthcare community.
“The way I challenge people is to say, when did you discover your gender?” Bagshaw says. “That makes them think because they say ‘I was that from birth’. No, you discovered what your gender is as you grew up. It’s a societal construct, really. But that’s far too abstract for people to get their heads around.
“I think the trans community is where the gay community was 30 or 40 years ago,” she adds. “There’s still homophobia but being gay is much more acceptable than it used to be. Hopefully transitioning gender will become the same sort of thing.”
As for the slight drop in users since 2022, Bagshaw’s view is that “like any medication that is new or used for a new person, there is a lot of use and it is acclaimed as a breakthrough. As use continues, it tends to settle as clinicians have experience and work out its best application to help people get the best outcome.”
Unsurprisingly in an area where the evidence remains uncertain, there has been pushback against the Cass Review and not just from Patha and Equality Australia.
In July, the British Medical Association called on the NHS to lift its ban on puberty blockers. In September it announced it was committed to a “neutral position” on the Cass Review* while it carried out its own evaluation.
In the US, experts from the Yale Law School and School of Medicine said the review contained “serious methodological flaws, including the omission of key findings in the extant body of literature” and the Endocrine Society criticised it as “very conservative” and also called for more funding and research.
In his response to Cass, Otago University clinical psychologist Paul Skirrow urged the public “to interpret the findings with some caution” as “many people will assume that this research suggests that puberty blockers and hormone treatments should never be offered, which would be mistaken”.
In a recent study, the Sax Institute in Australia reviewed 17 studies published between 2019 and 2023 and found puberty blockers to generally be “safe, effective and reversible” but added “the strength of this evidence remains low”.
Bagshaw co-authored a review in 2021 that concluded there are “significant psychosocial benefits” and that puberty blockers “appear to improve functioning, reduce suicidality, and aid in the management of comorbid mental conditions”.
There are buts, such as that “they do not impact the symptoms of gender dysphoria. One study raises the possibility that body image may worsen for some. Valid concerns remain about long-term physical outcomes, the lack of evidence for which remains a barrier to prescribing.”
Bagshaw and her co-authors add that it is important to articulate the potential negatives to young people and families, and that “it necessitates care and caution in prescribing, with monitoring of the effects on the adolescent’s body”.
None of that suggests the kind of medical recklessness that Tamaki seemed to be describing. As Bagshaw says, puberty blockers are “not handed out like lollies”.
But all medication carries risks, she adds. For example, “aspirins are incredibly harmful to the body”.
Even those who support puberty blockers tend to agree with Cass and Paul that further research is needed.
Otago University transgender healthcare specialist and Patha executive committee member Rona Carroll said in her response to the Cass Review, published by the Science Media Centre, that “the majority of evidence presented in most medical guidelines would not be classed as high quality” but “this is not unique to transgender healthcare”.
She added that “funding for further research specific to Aotearoa would be welcomed”.
She did not want to comment further until Doocey’s reports are released.
Debates about relatively obscure medicines are rarely this charged. Observers agree there must be a way to take the heat out of the argument.
Apart from stressing that the science is more nuanced than it appears from the extremes on both sides, it is important to remember there are vulnerable human beings involved.
That is a view that even Cass herself endorsed when she wrote in her review that “a compassionate and kind society remembers that there are real children, young people, families, carers and clinicians behind the headlines.”
* Clarification: The article has been updated to report the British Medical Association’s statement released on September 26. This said it was taking a “neutral” position on the Cass Review while undertaking its own evaluation. (September 30, 2024)