Complaint to the NZ Herald

PostingDad
11 min readApr 23, 2023
Photo by Tom Caillarec on Unsplash

Dear Sir/Madam,

I wish to formally complain about the Opinion piece by Jan Rivers in the 24/04/23 NZ Herald. I have provided a short summary below, and then a point by point explanation of the misleading or distorted evidence presented in the piece:

https://www.nzherald.co.nz/nz/jan-rivers-questions-mount-around-the-use-of-puberty-blockers-for-children/JVKMNIUYUVBXDPCFPYSNZ34RWE/

Summary:

The substantive amount of the article itself contains significant claims which are not supported by the evidence, which she does not include in the article. Particularly troubling are claims that;

  • “Evidence for puberty blockers is poor” which is not supported by the reviews stated
  • Claiming Dr Abassi was speaking purely about a lack of evidence and overtreatment, when he was advocating for further evidence and research due to the possibility of treatment being denied entirely
  • Claiming there was only one Puberty Blocking medication and that it was not safe for children, which is incorrect as there are multiple medications
  • Ignoring the evidence that the MoH already accounts for bone density issues in its documentation and consent forms
  • Dismissing the high rates of attempts at or completing of suicide by trans people, even as NZ and overseas studies support it
  • Claiming the Tavistock Clinic was closed (it has not closed) due to unsafe practices (the safety reasons outlined for the replacement of the Tavistock Clinic relate to waiting times and pressure on the service — the Tavistock Clinic do NOT prescribe puberty blockers/hormones directly but refer patients to two endocrinology clinics in Leeds and London Hospitals)
  • Implying that there is not a need for a diagnosis for gender healthcare by misrepresenting the University of Waikato guidelines, when the Ministry of Health clearly outlines an assessment pathway required for all patients.
  • Misrepresenting WPATHA’s updated guidance as “removing surgery age limits” WPATHA Soc 8 has clearly stated age limits for surgical intervention
  • Misrepresenting the Relationships and Sexuality Education guidance from the Ministry of Health as presenting “being transgender as an option to all primary school students” which it absolutely does not.
  • Claiming that the Ministry of Health and Ministry of Education engaging with LGBTQI expert charities, somehow means they encourage children to be transgender?

The following is a point by point critique of Ms. Rivers piece, highlighting some issues with accuracy and facts, as well as some deliberate misleading of the reader by omitting key information relevant to her argument. My points are in bold, and are evidenced with the included links:

Having last year removed advice that puberty blockers are a safe and reversible medicine, the Ministry of Health has said it will publish an evidence brief on the medicine in May.

The Ministry of Health has confirmed that they retain confidence in the safe and reversible nature if puberty blockers: https://www.stuff.co.nz/national/health/129962797/puberty-blockers-still-considered-safe-and-reversible-health-ministry-says

Update: Thank you to the reader who drew my attention to the MoH additions to this article which outlines the upcoming evidence brief: https://www.stuff.co.nz/national/health/300838494/trans-health-advice-scrubbed-following-complaints

A number of overseas reviews are likely to influence this decision. Those in the UK by NICE and Oxford University, Ireland, Finland, Sweden, Norway and Australia have shown evidence for the use of puberty blockers is poor.

As an example the NICE study did not find “evidence for the use of puberty blockers is poor”. They found multiple studies, but the nature of trans healthcare means that often studies did not have a “control” of young people not being given puberty blockers due to the nature of gender healthcare. One of the issues NICE raises is that the studies are of relatively small groups, representing the small numbers of patients who recieved gender healthcare (Pg.13). The issue here, as with that identified by Dr. Cass in the UK, is that it is hard to get statistically significant studies on such a small % of the population, especially when giving a “control” group would mean denying trans and gnc patients access to healthcare in the interest of research, which is an ethics breach of significant proportions.

https://web.archive.org/web/20220414202655/https://arms.nice.org.uk/resources/hub/1070905/attachment

The editor-in-chief of the British Medical Journal has written that much of the guidance from medical associations proposes treatments that are not supported by evidence and that the risk of overtreatment is real.

Dr. Kamran Abassi, Editor in Chief of the BMJ, statement was writing in favour of establishing a further evidence base of research, which is being conducted, and specifically warned about overtreatment, but also the ‘draconian laws now being introduced in some US states’ in the same sentence. Ms. Rivers has paraphrased the sentence to avoid mentioning this outcome, as it is one she seeks:

“Taking this route is essential: an evidence void not only exposes people to overtreatment but can also be used to deny people the care that they seek, such as through the draconian laws now being introduced in some US states”

https://www.bmj.com/content/380/bmj.p553

The NZ Media Council recognises there is a legitimate debate but there has been little media coverage of the issue here.

Searching NZ Media Council rulings, I can find very few references to puberty blockers, listed below:

Ms. Rivers complaining about Puberty Blockers: https://www.mediacouncil.org.nz/rulings/jan-rivers-against-tvnz/ which was not upheld.

Subsequent complaint from Simon Tegg which found no grounds to proceed: https://www.mediacouncil.org.nz/rulings/simon-tegg-against-tvnz/

December complaint about coverage of Jennifer Scott being trespassed from an MSD building: https://www.mediacouncil.org.nz/rulings/jennifer-scott-sarah-henderson-janet-bogle-rex-landy-and-hilary-oxley-against-newshub/ Only upheld on the correction Newshub issued.

Other sources show why the “safe and reversible” claims have had to go.

The Pharmac data sheet for the PB Goserelin says it must not be used in children. FDA advisory notifications advise of serious health risks.

This is deliberately misleading. PB Goserelin is not the only PB medication available to Pharmac.

As Pharmac clearly states in this OIA response, “Leuprorelin is Medsafe approved for use in the treatment of children with central precocious puberty”

https://pharmac.govt.nz/news-and-resources/official-information-act/official-information-act-responses/funding-of-gnrh-analogues-for-indications-not-approved-by-medsafe-children-and-adolescents/

By excluding Leuprorelin, Ms Rivers misleads the reader that Goserelin is the only PB medication available and that it is unsafe for children. She also avoids that Goserelin is open-listed, which as Pharmac states:

“Goserelin is open-listed. This means clinicians can prescribe goserelin when a patient and their doctor agree it’s a suitable treatment option. It is up to doctors to discuss the benefits and risks of each treatment with their patients and ensure the treatment is appropriate, whether or not it has been approved by Medsafe.”

Analysis of academic research has found that, after two years of use, the drugs were linked to abnormally low bone density in up to a third of young adolescents.

Ms. Rivers is representing ‘analysis of academic research’ as the source of this evidence.

On NZ’s Hauora Tāhine website this knowledge is represented clearly in the advice for parents and young people and is EXPLICITLY referenced in the existing consent forms: https://www.healthpoint.co.nz/public/sexual-health/hauora-tahine-pathways-to-transgender-healthcare/

Consent form 1: https://www.healthpoint.co.nz/download,a524eff3-14ac-4f26-aff7-16d2fd15b190.do

Consent form 2: https://www.healthpoint.co.nz/download,68cba24f-adde-4b78-bc42-aae76778025d.do

Dr Marci Bowers, president of the World Professional Association for Transgender Health (WPATH), has said that any male child whose puberty is fully suppressed will never orgasm, an important part of human loving, and their penis will not grow to full size.

This is anecdotal from remarks made by Dr Bowers. It is in no way substantiated by academic evidence.

There’s more. Children carefully selected by Dutch clinicians in the early 2000s for treatment are doing poorly compared with their peers. It appears that social transition makes puberty blockers more likely but children’s mental health does not improve.

Once a child is taking puberty blockers, cross-sex hormones follow but testosterone frequently causes pelvic pain encouraging hysterectomy and pain from chest binders leads to a greater likelihood of mastectomy.

I am assuming the Dutch study quoted here is this one: https://link.springer.com/article/10.1007/s10508-020-01660-8#Sec6 which says 96.5% of trans or gnc youth who use puberty blockers go onto hormone affirming treatment. Again this is after a detailed assessment of the needs of the patient.

A British study, which along with the Dutch study is quoted in the Interim Cass Report found a similar level (98%) of patients then using hormone affirming treatment, but patients reported positive experiences overall: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0243894

Pelvic pain is studied here, as a result of testosterone, but found: “Persistent menstruation, current or previous history of post-traumatic stress disorder, and experiences of pain with orgasm were associated with higher odds of pelvic pain after testosterone therapy.” and requiring further study of the androgen sensitivity of the pelvic floor. However, despite its occurrence to say it is ‘encouraging hysterectomy’ is misleading.

https://www.liebertpub.com/doi/10.1089/lgbt.2022.0187

Similarly chest binding is a simple way for trans and gnc people to reduce their dysphoria, and people use them without having used puberty blockers or being on cross-sex hormones. Like with any item of clothing, ensuring one fits and is worn for the appropriate amount of time is importance — wearing a binder does not lead ‘to a greater likelihood of mastectomy’.

Clinicians and others may tell parents their child will commit suicide without treatment. However, this is not supported by research and evidence shows it is rare.

A literature review of available research in 2016 found:

The suicide attempt rate among transgender persons ranges from 32% to 50% across the countries. Gender-based victimization, discrimination, bullying, violence, being rejected by the family, friends, and community; harassment by intimate partner, family members, police and public; discrimination and ill treatment at health-care system are the major risk factors that influence the suicidal behavior among transgender persons.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5178031/

Similar results were found in the NZ study: https://www.waikato.ac.nz/news-opinion/media/2019/ground-breaking-new-zealand-report-on-trans-and-non-binary-peoples-health-released

New Zealand rates of puberty blocker use are much higher than the UK, where the Tavistock Clinic’s Gender Service (GIDS) was closed due to unsafe practices.

The Tavistock Clinic has not yet closed, as the Interim Cass Report recommended that its single provider model be replaced with an expansion of gender healthcare in the UK. The concerns expressed by Dr Hilary Cass were related to the pressure on the service as the only provider and the potential harm caused to patients referred by the extremely long waiting list. It was not closed “due to unsafe practices”. More detail can be found in Dr. Cass’ interim report: https://cass.independent-review.uk/publications/interim-report/

In New Zealand, Dr Sue Bagshaw reports that 65 per cent of her clinic’s 100 patients receive them. The Tavistock GIDS clinic prescribed blockers to about 6 per cent.

The overall New Zealand rate is higher too. Pharmac data shows New Zealand has had 703 children on puberty blockers compared with about 1000 prescribed them in England over the same 10-year period.

Pharmac data shows 703 9–17 year olds on puberty blockers in 2020. The NZ healthcare system does not operate in the same was as England’s single-service model, meaning there is not a long wait list or the safety concerns raised by the Cass Review. Effectively, these numbers demonstrate a system working in a regionally devolved manner, which is what Dr. Hilary Cass recommended in her report.

The “guidelines for gender-affirming healthcare for gender diverse and transgender children, young people and adults in Aotearoa, New Zealand” require no diagnosis. Rather, clinicians are advised they should “recognise that each individual is the expert of their own gender identity”. That is, each child, regardless of their age, and any other mental health issues, is to be treated as an expert.

These are guidelines issued by the University of Waikato’s Transgender Health Research Lab, and the quoted passages refer to how medical staff should engage with patients, not how decisions about treatment are made. For instance the same guidelines outline:

“Utilising an informed consent process involves several conversations between the person and clinician(s) before they start treatments that have an irreversible component to increase certainty that they are adequately prepared and are making a fully informed decision. Health teams have a duty to approach care holistically. Involving team members with expertise in psychological health is important to identify and address any mental health needs. Social transition can be a stressful time for some people who may benefit from extra mental health support, but it is important to ensure that they consent to having this support and it is not enforced as a requirement for accessing gender affirming care.”

Equally the Hauora Tāhine website makes it clear that that while they consider patients to be experts in their own gender, there are examinations and assessments which must take place prior to beginning any treatment, which also involves detailed consent forms: https://www.healthpoint.co.nz/public/sexual-health/hauora-tahine-pathways-to-transgender-healthcare/

Treatment is already highly devolved and work is under way to make puberty blockers available from more general practices.

This is true! Treatment is highly devolved in the NZ medical system. That’s the sort of structure that the UK has been recommended to implement by Dr Cass. This is not a bad thing, it improves access to healthcare.

Moreover, the 2022 World Professional Association for Transgender Health standard has removed surgery age limits. Surgery, such as a double mastectomy, has already been performed on a New Zealander aged 16. (”Born in the Wrong Body”, The Listener, June 26, 2021).

WPATHA’s guidelines have NOT removed surgery age limits. The Standards Of Care, 8th Edition, introduces new guidelines and requirements for surgeons and sets a limit of age 15 or age 17 for specific treatments. These are also, again, guidelines and not necessarily the policy of the Ministry of Health.

https://apnews.com/article/gender-transition-treatment-guidelines-9dbe54f670a3a0f5f2831c2bf14f9bbb

Meanwhile, the Ministry of Education Relationship, Sexuality and Education Guidelines present being transgender as an option to all primary school children, who are encouraged to use their preferred name and pronouns.

The Relationship, Sexuality and Education Guidelines do NOT “present being transgender as an option to all primary school children”. The Primary guidelines mention “transgender” 10 times in the document:

Page 10 — Relating to Upholding Human Rights with a quote from the NZ Human Rights Commission

“All people have the same rights and freedoms, regardless of their sexual orientation, gender identity and expression, and sex characteristics (SOGIESC). SOGIESC is an umbrella term like Rainbow, LGBTQI+, and MVPFAFF. It includes people who are takatāpui, lesbian, gay, bisexual, queer, intersex, transgender, transsexual, whakawāhine, tangata ira tāne …”

Page 19 — Relating to supporting those who are transgender

“School cultures should acknowledge the sexual diversity of Aotearoa New Zealand communities. The culture should recognise and actively support the rights of those who identify as: • takatāpui, lesbian, gay, bisexual, queer, intersex, transgender”

Page 29 — Relating to a potential technology topic

In technology, ākonga can: challenge gender stereotypes in relation to design and materials, explore symbols linked to the gay and transgender rights movements,identify how gender expectations are embedded in technology, for example, in the design and style of power tools and other tools, the range of colours, textures, and design available for clothing. Explore the way toys, apps, and online games and activities are designed for a gendered audience.

The remaining 7 references are in the glossary for education professional to refer to.

Auckland University researchers asked thousands of 8-year-old children which gender they identified with.

This was part of a longditudinal study ‘Now we are 12’ which also asked 12 year olds about their ethnic identity as part of an ongoing research project. https://www.stuff.co.nz/national/health/300843183/kiwi-kids-have-strong-sense-of-ethnic-gender-identity-study-shows

The study can be found here: https://www.growingup.co.nz/now-we-are-twelve

It is not clear how this or her misleading criticism of the Relationship and Sexuality Education Guidelines relates to Ms. Rivers views on puberty blockers, at all? It appears to be a criticism of asking children a question, which they all answered.

Schools turn to “rainbow” advocacy groups that give extra attention and support to these children. Such interventions question the claim that no one encourages children to be transgender.

This critique of Schools turning to “rainbow” advocacy groups is inaccurate. The Ministry of Health and Education have long-standing and positive relationships with many LGBTQI organisations and charities who provide them with expert advice and support, including training teachers in sensitivity and managing students with diverse gender presentations. They do not “give extra attention and support to children”, and their work in professional development of teachers does not question the claim that “no-one encourages children to be transgender” which is a claim Ms. Rivers herself has made.

Given what the health system now knows about blockers, attempts to explain gender identities as if they are a neutral and cost-free option seem very unwise.

Having misrepresented what the health system now knows, this is an interesting opinion to close on. It is also one of the few opinions represented in the article.

Kind Regards,

John Palethorpe

Unlisted

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PostingDad

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