Newshub have aired a balanced 6 minute item on puberty blockers last Sunday night and published an accompanying article. The item was the first in New Zealand to present a sceptical view of puberty blockers and the journalist, Adam Hollingworth, and producers should be congratulated. We respond to several points and framings made in the item, and make recommendations for future media coverage.
Newshub titles the piece "Controversy brewing over transgender children's access to puberty blockers". This misleadingly frames every child presenting to an opposite sex imitation clinic as "transgender".
The reality is that if gender dysphoric children are not enculturated in opposite sex stereotypes while young ("social transition"), and are allowed to go through puberty, most will grow up to be gay, lesbian, or bisexual adults without gender dysphoria (Singh et al, 2021).
Problem: The transgender framing presumes that every child at a clinic has an innate "gender identity" at odds with their body. There is no scientific evidence for gender identity, and the causes of the child's distress are complex.
Recommendation: Use a neutral descriptor such as "gender non-conforming" or "gender dysphoric" to describe youth who experience distress with their social expectations imposed on their sex, or their body's sex characteristics. Highlight that research indicates that most of these youth are homosexual or bisexual.
Hollingworth interviews a child who has been taking blockers since they were 10 years old. The child gives their perspective on the benefits of blockers.
We think interviews with children on blockers raise ethical dilemmas for journalists, who understandably want to present the view of a subject with experience of the topic at hand. The dilemma is that children are impressionable and their views are shaped by their peers, caregivers and media consumption. The Bell Judgement confirmed children are unlikely to understand the long-term impacts, or the lifetime of medical costs, while clinicians who promote opposite-sex imitation can gain reputation as saviours. Without this context, the story could create the impression that a child's perspective on the benefits of experimental medical procedures is a substantive rationale.
Consider the cases of (a) genital surgeries on children with Differences of Sexual Development (DSD aka "intersex") and (b) Female Genital Mutilation (FGM).
Children with DSD sometimes have ambiguous or non-standard genetalia and may undergo controversial surgeries to align their genitals' appearance with a more standard appearance of their own, or sometimes opposite sex.
Girls in societies that practice FGM often have their genitals cut in ways that reduce sexual function and cause permanent scarring. The procedure is often extremely painful and traumatic.
Puberty blockers have comparable, though less immediately traumatic and more uncertain outcomes. Blockers, along with many DSD surgeries, and FGM are not medically necessary. Would the media interview a DSD child about their desire to be a "real" girl or boy? Or interview a girl about to undergo FGM who sees the procedure as a source of honour?
If they did, we assume the producers would anonymise the child and highlight their lack of ability to understand and consent to the procedure. The item might present a counter-view that the child has internalised an adult ideal for their body. The same should apply here. The item does present the views of Keira Bell in the following section, but does not touch on the lack of consent, or the reputational and monetary interests of the opposite-sex imitation industry.
Problem: Children are impressionable and have a limited ability to understand the impacts of a treatment on their future.
Recommendation: Highlight children's impressionabilty, clinicians conflicts of interest, and the money that the opposite-sex imitation industry makes from a lifelong patient.
Mother of a trans-identified child
The item follows with excerpts of an interview with the mother of a trans-identified child. She states that:
"The doctor had met my child on that day and within ten minutes had offered puberty blockers..."
The mother's experience contrasts with other reports which emphasised a much lengthier approach to medical decision-making. Her report reveals the cowboy culture at some clinics, and the consequences of a lack of regulation.
But it is also not clear if a lengthier process involving more professionals would ensure higher quality decisions. The only predictor of whether a child's distress would persist into adulthood in the Singh et al (2021) study was lower social class of the parents - a possible proxy for homophobic attitudes and the early conditioning of the child in an opposite-sex role.
Unlike the UK, where gender dysphoric children are assessed at the centralised Gender Identity Development Service (GIDS), the liberalised regulatory regime in NZ allows any GP or sexual health clinician to set themselves up as "gender doctor". If all the people who work at these clinics believe that an innate, immutable gender, the child's autonomy to choose treatment, and the importance of reinforcing the child's beliefs, then a team of such people will not fundamentally alter treatment decisions.
Problem: The viewer may expect that clinicians have a neutral point of view, and follow a careful diagnostic process.
Recommendation: Highlight how opposite-sex imitation clinics in NZ have shifted medical decision-making authority to the child, and discharged their responsibility to investigate and treat underlying causes, rather than immediate symptoms.
Dr (Dame) Sue Bagshaw
Dr Bagshaw is a paeditrician and an opposite-sex imitation clinician based in Christchurch. She makes several claims which we breakdown below:
"I don't have too much problem [with prescribing blockers] because they're reversible. That's the main message I'd love you to get across is that these drugs are reversible"
This website details several experts who disagree with this claim and the item does a good job of presenting the counter view, quoting the NHS and Dr Julia Mason. Bagshaw seems convinced that blockers are reversible but the literature review she had a student perform over Summer found potential impacts on brain maturation. We are unable to reconcile these statements. Bagshaw should be forthcoming with the research that shows that any impacts on brain function are recovered after blockers are discontinued, or qualify her statements as speculative.
"I think a child of 12 or 13 definitely knows their mind. They might not have a mind that agrees with the adult mind but they definitely have a mind,".
Unpacking this statement, what does it mean to 'know your mind'? The first part of the statement confuses two qualities:
- Being strong willed and determined - this quality is sometimes described as 'knowing your own mind'.
- Being able to determine a relatively fixed aspect of oneself -in this case, to diagnose oneself as a lifelong transsexual.
We agree that children can be strong-willed but disagree that a child is able to detect, through introspection, an authentic opposite-sex self. Introspection is one of the most unreliable sources of information in psychology for adults, let alone children (Pronin, 2009).
The second part of Dr Bagshaw's statement is odd. Who has the 'adult mind'? Is Bagshaw suggesting that the child will come to regret their decision as an adult?
"I'd rather keep them alive so they don't suicide and get into alcohol and other drugs than wait and go 'oh dear we're too late'," she says. Dame Sue thinks she's saving some of their lives. "Because they're so intense in their emotions they feel like if they don't get acknowledged life's over, it's not worth living."
Dr Bagshaw believes that without blockers the child will be more likely to commit suicide. There is no evidence to support this claim (see Biggs' critique of Turban et al (2020)). Adolescent suicide is rare. Trans identified youth do have elevated of risk of suicidal ideation and self-harm behaviour in line with other gender-non-conforming gay and lesbian youth. Nobody suggests that LGB youth must take experimental drugs to prevent their imminent suicide.
If actual suicide rates are higher, and puberty blockers have been prescribed to this demographic for over a decade, then it is also not clear how blockers have helped prevent suicide. As the item points out, blockers were linked to increases in suicidal ideation and self-harm behaviour (Carmichael, 2015).
Bagshaw is correct that adolescents have intense emotions and seek acknowledgement, but this is common amongst adolescents in general. Perpuating the myth that without blockers, a common outcome is the child’d suicide goes against guidelines to (a) not present suicide as a common response to hardship, and (b) oversimplifying the reasons for suicide.
Problem: Proponents of puberty blockers claim that blockers are necessary to prevent suicide. There is no scientific basis for this claim.
Recommendation: Challenge interviewees to conform to established suicide reporting guidelines.
Ministry of Health (MoH)
“The Ministry of Health to Newshub that because each person’s gender expression is unique, it is unable to provide figures for the number of transitions and detransitions each year”
This is offensive. MoH consider detransitioners, people recovering from opposite-sex imitation malpractice like Keira Bell, to be a ‘unique gender expression’. The Ministry's ‘unique gender expression’ framing attempts to shift responsibility for medical harm from medical authorities to the people who were children at the time the medical pathway was initiated.
A timely report from Stuff reveals that the reluctance to gather or release health statistics is part of a broader pattern of obfuscation at MoH.
While the Newhub item represents a breakthrough on an important topic, reporting of this issue is nonetheless in its infancy. Our analysis shows that reporting is often at odds with the way other sensitive topics would be handled. Complex issues of gender dysphoria and sexuality are simplified to “transgender”, and child voices are called on to set the scene and ethical framework in which the rest of the story is understood. The issues of iatrogenic medicine and consent were not addressed.
The story is an opening to a more detailed exploration that is required. NZ has the most deregulated approach to opposite-sex imitation medicine, and this requires a full length exploration of the issues.