Puberty Blockers And The Hippocratic Oath

Saturday, 14 September 2024, 11:53 pm
Opinion: Ian Powell

30 August 2024

I am proud of the fact that despite some criticism (including vitriol) I have taken a public position for trans rights and against the bigotry of transphobia.

The lightning rod for this was the events associated with, and aftermath of, the visit to New Zealand of controversial far-right English transphobe ‘Posie’ Parker nearly 18 months ago.

Transphobic bigotry discussed in my Political Bytes blog

I discussed this in my separate politics blog Political Bytes in two different posts:        Class, transphobia and street democracy (2 April 2023) and Call transphobia by its real name – sickening bigotry (1July 2023).

Hippocrates and ‘first do no harm’

I have also posted twice in Otaihanga Second Opinion on the importance of the Hippocratic Oath, in particular ‘First do no harm. The first was in the wider context of health system leadership: An oath that stands the test of time (5 February 2022).

The second was in the context of the ethical predicament of medical practitioners working for Health New Zealand (Te Whatu Ora) over the government’s irresponsible decision to repeal tobacco control legislation: Health leadership, tobacco control and a sacred oath (14 July 2024).

Applying ‘first do no harm’

There is an argument that ‘first do no harm’ should be applied by those skeptical of trans rights to the point of being cruelly transphobic.

Before voicing opposition or espousing prejudice they should first think of the harm to the targets of their wrath risks being might be one of the consequences.

In my second above-mentioned Political Bytes post on transphobic bigotry I included a cautionary note in respect of puberty blockers for children and young people. The Hippocratic Oath is also relevant here.

I referred to the interim report (February 2022) of what has become known as the Cass Review which focussed on the clinical services provided to children and young people seeking help from the National Health Service (NHS) in the United Kingdom to resolve gender-related stress.

The interim report raised serious concerns, particularly about the robustness of the evidence relied upon for puberty blocking and the need for regional paediatric hubs to replace the existing single gender identity development service at Tavistock and Portman.

My concluding comment in that post was:

The review’s warning about the approach to puberty blockers is important. It should be incorporated into a more cautionary approach in New Zealand as further evidence and learnings unfold.

The Cass Review

Dr Hilary Cass is a British paediatrician who, prior to chairing this review, was known for chairing the British Academy of Childhood Disability, establishing the Rett Clinic for children with the Rett syndrome neurodevelopmental disorder, and for developing palliative care for children.

Her final report was published on 10 April this year: Final Cass Review report. Among its findings was that while much has been published on puberty blockers:

… systematic evidence reviews demonstrated the poor quality of the published studies, meaning there is not a reliable evidence base upon which to make clinical decisions, or for children and their families to make informed choices. 

Further:

The strengths and weaknesses of the evidence base on the care of children and young people are often misrepresented and overstated, both in scientific publications and social debate.

The controversy surrounding the use of medical treatments has taken focus away from what the individualised care and treatment is intended to achieve for individuals seeking support from NHS gender services.

The rationale for early puberty suppression remains unclear, with weak evidence regarding the impact on gender dysphoria, mental or psychosocial health. The effect on cognitive and psychosexual development remains unknown.

The use of masculinising / feminising hormones in those under the age of 18 also presents many unknowns, despite their longstanding use in the adult transgender population. The lack of long-term follow-up data on those commencing treatment at an earlier age means we have inadequate information about the range of outcomes for this group.

Clinicians are unable to determine with any certainty which children and young people will go on to have an enduring trans identity.

For the majority of young people, a medical pathway may not be the best way to manage their gender-related distress. For those young people for whom a medical pathway is clinically indicated, it is not enough to provide this without also addressing wider mental health and/or psychosocially challenging problems.

The Review takes a balanced approach to the challenge of using puberty blockers safely:

Innovation is important if medicine is to move forward, but there must be a proportionate level of monitoring, oversight and regulation that does not stifle progress, while preventing creep of unproven approaches into clinical practice. Innovation must draw from and contribute to the evidence base.

Cass Review recommendations

While not expressly saying so, Review’s recommendations are consistent with a ‘first do no harm’ approach over how and when  puberty blockers might be used for those young people who are looking to transition.

In summary:

• Services must operate to the same standards as other services seeing children and young people with complex presentations and/or additional risk factors.
• Expand capacity through a distributed service model, based in paediatric services and with stronger links between secondary and specialist services.
• Children/young people referred to NHS gender services must receive a holistic assessment of their needs to inform an individualised care plan. This should include screening for neurodevelopmental conditions, including autism spectrum disorder, and a mental health assessment.
• Standard evidence based psychological and psychopharmacological treatment approaches should be used to support the management of the associated distress from gender incongruence and cooccurring conditions, including support for parents/carers and siblings as appropriate.
• Services should establish a separate pathway for pre-pubertal children and their families. ensuring that they are prioritised for early discussion about how parents can best support their child in a balanced and non-judgemental way. When families/carers are making decisions about social transition of pre-pubertal children, services should ensure that they can be seen as early as possible by a clinical professional with relevant experience.
• NHS England should ensure that each Regional Centre has a follow-through service for 17–25-year-olds; either by extending the range of the regional children and young people’s service or through linked services, to ensure continuity of care and support at a potentially vulnerable stage in their journey. This will also allow clinical, and research follow up data to be collected. 
• There needs to be provision for people considering detransition, recognising that they may not wish to re-engage with the services whose care they were previously under.
• A full programme of research should be established to look at the characteristics, interventions and outcomes of every young person presenting to the NHS gender services.
• The puberty blocker trial previously announced by NHS England should be part of a programme of research which also evaluates outcomes of psychosocial interventions and masculinising/ feminising hormones.
• The option to provide masculinising/feminising hormones from age 16 is available, but the Review recommends extreme caution. There should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18 years.  Every case considered for medical treatment should be discussed at a national Multi- Disciplinary Team.
• Implications of private healthcare on any future requests to the NHS for treatment, monitoring and/or involvement in research, and the dispensing responsibilities of pharmacists of private prescriptions needs to be clearly communicated.

These are not the recommendations of an anti-transgender or anti-puberty blogs. Instead they are recommendations of how best to respect the right of children and young people experiencing gender related distress should receive safe, holistic evidence-based healthcare.

There is rigour behind the report. It was peer reviewed including by the University of York. While critical of the absence of randomised surveys on the effects of puberty blockers, the Review did consider other surveys where they were well-designed and conducted.

While concerned about the lack of information on the longer-term implications of puberty blockers, the Review did not recommend that they be banned.

The Cass review was also concerned about the negative effects of toxic atmosphere in which discussion over the efficacy of puberty blockers occurred.

This concern was taken further in The Guardian (12 April) by Hannah Devlin (science correspondent) and Ian Sample (science editor): This isn’t how good scientific debate happens.     

Contrary critique

There is a contrary published critique of the Cass Review by scientist Dr Cal Horton arguing that it represents Cis supremacy in the approach to healthcare for trans children.

It was published on 14 March in advance of the Review’s publication: Cis supremacy. While this critique is substantial it falls down, in my view, because the Cass Review was not considering trans rights, gender transition, or transgenderism.

Instead the Review focusses on the much narrower medical issue of the evidence over the efficacy of puberty blockers. Its recommendations centred on ensuring that puberty blocking was conducted in a way that was medically safe.

Dr Horton probably has a deeper understanding of transgenderism and trans rights than Dr Cass. But that was not the purpose of her review.

Opportunity to unite behind evidence informed care

Instead I find more compelling the editorial by British Medical Journal Editor-in-Chief Dr Kamran Abbasi (11April): An opportunity to unite behind evidence informed care in gender medicine.

Dr Abbassi is also Visiting Professor at the Department of Primary Care and Public Health based in the Imperial College in London. He is also a respected cricket writer and broadcaster (do credentials get any better than this but I would say that!).

Particularly impressive has been his expansion of international editions of the BMJ and his position that medicine cannot exist in a political void.

British Medical Journal editorial affirms Cass Review including its methodology

His editorial goes to the heart of the Cass Review: “Her stated ambition is to ensure that those experiencing gender dysphoria receive a high standard of care.”

Further, “Her conclusion is alarming for anybody who genuinely cares for child welfare: gender medicine is built on shaky foundations.”

Dr Abbassi rejects a criticism the Cass review that:

…it set the methodological bar too high for research to be included in its analysis and discarded too many studies on the basis of quality. In fact, the reality is different: studies in gender medicine fall woefully short in terms of methodological rigour; the methodological bar for gender medicine studies was set too low, generating research findings that are therefore hard to interpret….Offering treatments without an adequate understanding of benefits and harms is unethical.

He concludes with a blend of compassion and insights underpinned by the Hippocratic Oath:

People who are gender non-conforming experience stigmatisation, marginalisation, and harassment in every society. They are vulnerable, particularly during childhood and adolescence. The best way to support them, however, is not with advocacy and activism based on substandard evidence. The Cass review is an opportunity to pause, recalibrate, and place evidence informed care at the heart of gender medicine. It is an opportunity not to be missed for the sake of the health of children and young people. It is an opportunity for unity.

Is Aotearoa New Zealand caught in a “terrible trap”?

Before the final Cass Review was published (but after its interim report was) Charlotte Paul, an eminent epidemiologist and Emeritus Professor in the Department of Preventive and Social Medicine at the University of Otago, published her own assessment of the puberty blockers controversy in North & South (December 2023):        A terrible trap? 

She called for a review of the use of puberty blocking hormones for children with gender dysphoria noting that while more countries are taking action to restrict the use of puberty blocking hormones, in New Zealand little had happened.

Professor Paul describes New Zealand as becoming more of an outlier in our increasing use of puberty blocking hormones. Supporting her statement she reports that:

In 2022, 416 young people aged 12-17 were taking puberty blocking hormones, compared to 48 in 2011, the first year of use for gender dysphoria. We have 11 times the rate of use as England: 110 per 100,000 versus 9 per 100,000. We also have no minimum age for prescribing. If puberty starts at 10 or 11, these children are eligible for blocker.

She also reproduces a Pharmac graph on the number of young people in New Zealand having puberty blockers from 2006 to 2022.

Paul’s overriding concern is the unknown long-term effects of puberty blockers and the apparent absence of appropriate medical caution in New Zealand.

Her article is wider than this, She delves into both the unfortunate level of toxicity over the debate and her endeavours to persuade the Ministry of Health to review their use. While interesting it is not sufficiently relevant to the purpose of this post.

Her argument about calling the situation “a terrible and tragic trap” brings in a level of subjectivity. This does not make it wrong; in fact, while debatable, it is an interesting considered read.

But my focus is on the empirical evidence. What Professor Paul provides reinforces the importance of reviewing how, not whether, New Zealand’s health system uses of puberty blockers.

How should New Zealand respond to the Cass Review

The Ministry of Health has been looking at the evidence over puberty blockers but its last reference to it was December 2023 – essentially work in progress: Health ministry update on evidence brief.   

Ruth Hill reports on Health Ministry’s long-awaited ‘evidence brief’ on puberty blockers

The Cass Review was reported by experienced Radio New Zealand journalist Ruth Hill (11 April): ‘Evidence Brief’ and  Cass Review.

Hill reports that the Ministry of Health’s long-awaited ‘evidence brief’ on puberty blockers was expected to be released the following week.

However, this does not appear to have materialised; presumably in light of the issues raised by the Cass Review.

She also reported that Health New Zealand had commissioned the Professional Association of Transgender Health Aotearoa (PATHA) to update the national guidelines and referral pathways for gender-affirming healthcare. This work was expected to be completed by August.

While it is good for PATHA to be involved, it is compromised by its reported rejection of the findings of the Cass Review suggesting that it ignored trans or non-binary experts and was influenced by transphobic forces. As Hill reports, Professor Cass has rejected such claims.

If the Hippocratic Oath is to be respected then the Cass Review should be accepted as a credible piece of research that should better inform our health system’s approach to puberty blocker safety.

It is not advocating the halting of puberty blockers; instead it seeks to ensure that safety of vulnerable children is at the forefront. There are loud alarm bells over long-term harmful risks that can’t be ignored. The Ministry of Health needs to take the lead.

It is good that PATHA is involved as it brings a unique expertise. However, drawing up guidelines in light of the Cass Review requires wider involvement including the medical colleges beginning with general practitioners, physicians and psychiatrists.

Transphobia is not the winner of the Cass Review although no doubt this obnoxious bigotry will continue to endeavour to exploit it.

In my view applying ‘first do no harm’ to how puberty blockers should be considered is good for trans rights and bad for the bigotry of transphobia. Hippocrates would concur, at least in my opinion.

© Scoop Media

Ian Powell

Otaihanga Second Opinion is a regular health systems blog in New Zealand.

Ian Powell is the editor of the health systems blog 'Otaihanga Second Opinion.' He is also a columnist for New Zealand Doctor, occasional columnist for the Sunday Star Times, and contributor to the Victoria University hosted Democracy Project. For over 30 years , until December 2019, he was the Executive Director of Association of Salaried Medical Specialists, the union representing senior doctors and dentists in New Zealand.

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