Rushed medical transitions can have tragic consequences for vulnerable young people. One example is the story of Zahra Cooper, as told by the New Zealand Herald in a compelling video documentary. Zahra is a young New Zealand woman who “after searching the internet and watching YouTube videos about transgender people… realised she felt… like she was trapped in the wrong body”. She was assessed by a psychiatrist, who failed to detect her autism spectrum disorder. Her psychiatrist diagnosed her with gender dysphoria (a clinical term for profound discomfort with your biological sex).
Zahra started taking testosterone to treat her gender dysphoria. Instead of improving, her mood worsened significantly. Her endocrinologist failed to follow up on her progress, and she attempted suicide twice. She realised that gender transition had worsened her mental health. She decided to stop taking testosterone, and her distress abated. She was, however, left with a permanently deepened voice. The damage her course of testosterone may have caused to her long-term health is unknown. She is still often mistaken for a man, which she understandably finds frustrating and distressing.
An article in the New Zealand Listener tells a similar story. A young Kiwi woman, who uses the pseudonym “Rachel”, started taking puberty blockers at age 14. She was prescribed testosterone shortly afterwards, and had her breasts surgically removed at age 16. She had her womb removed at age 18. By age 22, she was “swamped by regret”.
Rachel now says, “It was almost like I woke up from a weird dream – what was going on? Transgender ideology stopped making sense to me and I thought, ‘Wow, with time and the right support, I could have lived perfectly happily as a masculine lesbian woman’”. Her medical treatments have left her permanently medically dependent on oestrogen. She will live with the consequences of her surgeries for the rest of her life.
In another similar article, a New Zealand mother explains that her child “met some trans people online on a gaming site”. Suddenly, her child started identifying as transgender. She felt that her child was subsequently rushed into medical gender transition:
I told the doctor at the clinic about my concerns, the suicide of my son’s father when he was four, the depression in his wider family, his [autism spectrum disorder]. It made not a whit of difference. He received no counselling, just affirmation.
In what reports from within the trans community suggest is a recurrent pattern, after transitioning, her child broke off all contact with family and friends:
I have neither heard from nor seen him since. He doesn’t reply to texts, phone calls or letters. I am bereft. I lie awake at night and think of the funny little boy I raised and my heart breaks. He has not only cut me out of his life but others close to him as well; his Big Buddy who has been his mentor since he was seven, his music teacher, his older brother and sister who live overseas. I assume that he is being influenced by others. I know that activists tell kids that if their parents aren’t 100% on board with their transition they should be excised from their lives.
He and I have been through so much together in the past fourteen years and I never imagined that something like this could happen to us.
I saw this mother speak at a recent conference, and it was heartbreaking. But are these stories just isolated incidents, or signs of a much larger medical tragedy?
There’s no need to rush transition
Gender activists sometimes claim that youth transition is ‘lifesaving’, and that transition safeguards create an unacceptable suicide risk. This claim is groundless and irresponsible. As the British Medical Journal has reported, multiple systematic reviews have found scant evidence for the safety or effectiveness of youth transition. Researchers have found serious flaws in the studies often cited to justify these treatments.
As The Economist recently reported, “Until now, transitioning has been justified by the hope that it could ease distress. Though some studies have found short-term improvements in mental health, these disappear in long-term studies”. For example, a European 2021 study tracked 873 patients who started taking cross-sex hormones. Some subgroups of patients initially experienced a small lift in mood, possibly due to placebo effects. However, these benefits disappeared within three years of initiating treatment.
Similarly, the best evidence suggests that medical transition does not mitigate suicide risk. For example, a 2020 study examined suicide rates among 8,263 people who medically transitioned at the Amsterdam University Medical Centers. It found that “suicide deaths occurred during every stage of transitioning” and “the incidence for observed suicide deaths was almost equally distributed over the different stages of treatment”.
Gender activists often cite early studies claiming low regret rates for medical transition. However, these studies were based on relatively cautious treatment models, and often failed to locate patients who dropped out of treatment. Recently, more comprehensive follow up studies have found that as many as 30% of people who start taking cross-sex hormones stop taking them within four years.
Shamefully, many major medical associations have adopted a stance on youth medical transition which appears to be more shaped by gender activism than science. However, other professional groups, including the Royal Australian and New Zealand College of Psychiatrists, have advocated for a more cautious approach. Finland and Sweden have both strictly limited the availability of these treatments, and Britain is moving in the same direction.
Comprehensive assessment is crucial before transition
Medical gender transition has serious health risks, including infertility, sexual dysfunction, cardiovascular risks, surgical complications, and chronic pain. The damage done is often permanent. Because of this, basic safety standards require “mental health support and comprehensive assessment for all dysphoric youth before starting medical interventions”. This support helps ensure that people who transition enter the process with realistic expectations and sound insight into their own motives. Both these factors are key to a successful outcome. If done properly, a careful process of assessment and exploration takes months or years to complete.
Activists claim that patients themselves can accurately determine whether they will benefit from medical transition, but this is demonstrably false. Researchers at the Tavistock clinic in London have reported multiple instances of youth seeking medical transition who decided against it during psychosocial assessment, often because they “no longer felt that their gender identity was incongruent with their biological sex”. Conversely, multiple examples suggest that the removal of proper safeguards can lead to transition regret. Clinical psychologist Jordan Peterson’s heart-wrenching interview with detransitioner Chloe Cole has recently brought this problem to widespread attention. In response to similar instances, Britain’s National Health Service has introduced draft guidelines requiring exploratory assessment prior to medical transition.
Clinicians who adopt a transition-on-demand approach are also starting to see legal and professional consequences. For example, in Canada, a woman has filed a lawsuit against eight health professionals involved in her medical transition. The National Post reports:
“Michelle’s stated desire to become transgender was never challenged and it was treated to the exclusion of her other serious mental health issues, closing the door to alternative treatment options,” her statement of claim says.
The claim says the defendants “permitted Michelle to self-diagnose as transgender and prescribe her own treatment without providing a differential diagnosis or proposing alternative treatments”.
If alternatives were pursued, the claim says, Zacchigna could have “learned to live with her body without surgical or hormonal treatments”.
“Michelle has struggled to come to terms with the permanent changes her hormone treatments and hysterectomy surgery have caused: a low voice, male-pattern balding, facial hair, an enlarged clitoris, a flat chest, and the inability to ever become pregnant. All of this has caused her to suffer from a worsening of her depression,” her claim says.
Similarly, last year, a British doctor was struck off the register for, amongst other failings, initiating medical transition of young people with inadequate assessment. One of his patients later committed suicide. The medical tribunal found that:
At the conclusion of the process, in every case the patient was prescribed the treatment which they had sought at the outset. On no occasion had Dr Webberley disagreed with the diagnosis sought or failed to prescribe the treatment sought, neither did he seek to discuss or offer alternatives to treatment… In the Tribunal’s view it was illustrative of an apparent intention to prescribe according to a patient’s wishes and not because Dr Webberley had, following an adequate critical and objective assessment, made a diagnosis and concluded that the treatment was clinically indicated.
Yet prescribing “according to a patient’s wishes” appears to be standard, even recommended, medical practice in New Zealand.
Safeguarding is poor in New Zealand
In New Zealand, puberty blockers and hormonal treatments appear to be readily available. According to Newshub, the government’s most recent budget included NZ$2.2 million to publicly fund these services, and NZ$2.5 million to train family doctors in “advising trans youth”. Counting Ourselves, a 2018 survey of people identifying as trans or non-binary, found that 81% of those who had asked a doctor for cross-sex hormones had been prescribed them. A University of Otago epidemiologist has reported that many New Zealand health professionals are concerned that puberty blockers and cross-sex hormones are being overprescribed. Worryingly, she says that most of these health professionals are afraid to speak out publicly.
As mentioned above, pre-transition mental health assessment is a critical safety measure. Unfortunately, in New Zealand these assessments may often be perfunctory or non-existent.
A 2019 study found that ‘gender affirming care’ was available without a mental health assessment in several regions of New Zealand. (‘Gender affirming care’ is a euphemism for medical transition). Counting Ourselves likewise found that under half of respondents had received a mental health assessment. Often, this was because they didn’t know where to go or couldn’t afford it. This lack of safeguarding appears to be getting worse due to activist pressure to remove perceived barriers to transition. One Newshub article suggests that some New Zealand doctors are willing to offer puberty blockers to teenagers within ten minutes of meeting them.
Even in regions where mental health assessments exist, they may not always be effective. The activist group Gender Minorities Aotearoa explains that if you need to ‘pass’ a mental health assessment “you can probably guess the ideal answers”. They also explain exactly what those ideal answers are. For example, they advise readers to “be sure to tell your healthcare provider how positively HRT [Hormone Replacement Therapy] will impact your life” and “let your provider know that you understand all the possible effects of HRT”. They additionally suggest that “it may help if they know it’s not a passing idea – if you’ve felt this way for a long time, tell them”.
Gender Minorities Aotearoa also remark that in New Zealand, the standards for ‘passing’ a mental health assessment are quite relaxed, explaining that “none of the less ideal answers should prevent you from being prescribed HRT. The only ‘hard nos’ are hormone-sensitive cancers (such as testicular or cervical)”. Consistent with this advice, the Guidelines for Gender Affirming Healthcare for Gender Diverse and Transgender Children, Young People and Adults in Aotearoa, New Zealand state plainly that “having… mental health concerns does not mean gender affirming care cannot be commenced”.
The New Zealand Psychologists Board, which regulates and disciplines psychologists in New Zealand, has endorsed these guidelines. Its own guidelines add that “assessment should be based on the principle of informed consent, rather than on a traditional gatekeeping model” and state that “clients do not need to have identified as trans or nonbinary for a particular time” before commencing medical transition.
The booklet Supporting Aotearoa’s rainbow people: A practical guide for mental health professionals is even blunter, advising clinicians that “Health professionals should trust the self-determination of an individual and that they know what’s best for them when it comes to gender-affirming healthcare”.
A brief investigation of the information provided to young patients provides little comfort. Auckland’s youth medical transition service promises patients that they “recognise that you are the expert when it comes to your gender”. They describe their initial assessment as “a 90 minute appointment where we get to know you and identify any goals you may have for your journey”, where “what we talk about is guided by you”. They say to expect that topics in this initial assessment may include “medications such as puberty blockers and hormone treatment” and “the possibility of storing sperm”. Their information page also recommends the Gender Minorities Aotearoa website, where as mentioned patients can find information on the ideal responses for ‘passing’ a mental health assessment. None of this gives the impression of a rigorous screening process.
Nor is medical transition restricted to adult patients, or even to older teens. Alarmingly, evidence suggests that some New Zealand doctors are starting under-16s on cross-sex hormones. Gender Minorities Aotearoa claim that cross-sex hormones are “usually prescribed from age 14 – 16” in New Zealand, although they warn that getting hold of these drugs can be “a little more complex” for children under the age of 16. Consistent with this, the New Zealand Guidelines for Gender Affirming Healthcare suggest that there may be “compelling reasons, such as final predicted height, to initiate hormones prior to the age of 16 years”. The New Zealand medical website Family Doctor even suggests that under “exceptional circumstances… people under 16 may be allowed to start [hormonal] treatment without the consent of their parents” (emphasis added).
We can hope that only an extreme fringe of doctors would willingly prescribe cross-sex hormones to children in their early teens. However, puberty blockers appear to be quite freely available to younger New Zealand children. Reports suggest that we have taken a particularly incautious approach to prescribing these medications. For example, it was not until September 2022 that our Ministry of Health begrudgingly removed a claim on its website that puberty blockers are “safe and fully reversible”. In contrast, the United Kingdom’s National Health Service revised similar guidance two years earlier, to highlight the potentially serious risks of these drugs.
Some activists and medical professionals characterise puberty blockers as a ‘pause button’. However, ‘accelerator pedal’ seems like a more accurate description since almost all children who take them progress to cross-sex hormones (usually at age 16).
A recent article in the Listener reported that 505 New Zealand children aged between 10 and 17 were prescribed puberty blockers in 2020. A few of these children may have been prescribed these drugs to treat conditions other than gender dysphoria. However, it’s reasonable to assume that for most of these children, these drugs were the first step towards medical transition.
While a significant number of gender questioning children take puberty blockers, the majority don’t seem to. Counting Ourselves found that in 2018, about 17% of self-identified trans and non-binary youth (aged 14 to 24) had been prescribed these drugs. This proportion has probably increased somewhat since then, given that the aforementioned Listener article reported that the number of children prescribed puberty blockers increased by 66% between 2017 and 2020.
Certain medical practices seem particularly enthusiastic about puberty blockers. One disconcerting example is Youth 298, a health centre in Christchurch that serves “vulnerable young people aged between 10 and 25”. Youth 298 has roughly 500 registered patients (a doctor from this clinic kindly provided me with this information by email). This medical practice has estimated that about 100 of their patients are “gender diverse”, and that about 65% of these are taking puberty blockers. This equates to about 13% of their entire reported patient population. In contrast, the Youth 298 doctor I contacted told me that most Christchurch general medical practices don’t prescribe puberty blockers. Parents would be well advised to choose their children’s doctors carefully.
A looming medical scandal
New Zealand doctors, psychologists, and medical regulators would be well advised to pay close attention to recent developments in the UK. The Tavistock clinic, which is the UK’s leading gender clinic for children, is being closed down over concerns that its services are “not a safe or viable long-term option” for the treatment of gender questioning youth. The Tavistock clinic is also being sued for criminal negligence. Lawyers for the affected families claim that patients were “rushed into taking life altering puberty blockers without adequate consideration or proper diagnosis”, resulting in “physical and psychological permanent scarring”. The Times described the reasons for the closure of the Tavistock in a devastating leading article:
The damage done is immeasurable. No one knows how years of ideological dogma, inappropriate treatment and a culpable failure to consider the overall mental welfare of the children treated by the Tavistock Clinic will affect the thousands referred to its Gender Identity Development Service… It naively confused sexual orientation with gender identity, accepted at face value all declarations by children that they were born in the wrong body and treated all complex problems through the prism of gender…. Whistleblowers were denounced as transphobic…. When at last the NHS decided to investigate, the report by Dr Hilary Cass was appalling. The clinic had failed to keep accurate records of all the children treated with hormones after they grew up. There was no long-term monitoring of the outcomes, no attempt to look at other factors affecting mental wellbeing, and no distinction between clinical experience and the shrill activism of those who insisted that trans rights were above all a matter of social and political acceptance… Worries about the Tavistock’s obtuse ideology have long been highlighted by writers for The Times. At last the government has listened.
The similarities between the Tavistock clinic and New Zealand’s health system are striking. In both the UK and New Zealand, ideologically-motivated pressure groups have had an undue influence on medical practice. In both countries, there has been a distinct lack of monitoring, followup, and evaluation of medical transition. In fact, recent comparisons have found that the prescription of puberty blockers is “less controlled” and more than ten times as frequent in New Zealand than in the UK.
As the Times article describes, the UK government eventually took notice of public outcry. They organised an independent review by paediatrician Hillary Cass, which led to the closure of the Tavistock clinic. The Tavistock review suggests a useful way forward for our country. We need someone with Dr Cass’s courage, compassion, and scientific integrity to examine how our health system is treating gender identity concerns.
We still have the opportunity to adopt a more science-based, more humane, and less ideological approach to supporting gender questioning youth. If we don’t take action now, we will be counting the costs to our children’s health for decades to come. History will judge those who stood up for what was right, and those who did not.