Open Letter to the Ministers of Health
and Minister for Mental Health

Dear Minister Reti and Minister Doocey,

We write to you as a group of senior New Zealand Paediatricians and other Clinicians who work with young people as part of our practice and are keen to see positive outcomes for our next generation.

As the ministry is currently in the process of reviewing literature regarding the use of puberty blockers in New Zealand for an evidence brief, we feel compelled as medical professionals to urge you to carefully consider the recommendations of the British NHS Cass-Review whose findings are utterly relevant for the treatment of gender confused children in New Zealand. England, Scotland and Wales have all changed course in response to the report's recommendations. The fact that New Zealand has a twelve times higher prescription rate of puberty blockers than the UK has ever had shows just how prevalent and pressing this issue is in our nation.

We therefore urgently ask you for:

1. An immediate suspension of the use of puberty blockers and cross-sex hormones for our gender confused children and adolescents in New Zealand
2. The full implementation of the provisions of the Cass-Review into the clinical care guidelines; notably the 'watchful waiting' approach vs the 'affirmation model'

Background

In 2020 the UK National Health Service commissioned renowned paediatrician Dr Hilary Cass as Chair for an Independent Review of gender identity services amidst growing concerns about the 'affirmation model' of treatment for trans-identifying children and adolescents. It is the largest systematic review of evidence to date on gender-transition medicine.

Outcome

The Review's outcome is damning of ideologically driven 'standards of treatment', citing a lack of sound scientific evidence as a base to support them.

In particular

• There is no evidentiary basis for medical gender-affirmation therapies in children.
• The popular claim that gender affirmation treatment prevents suicide was found to be without a credible evidence base.
• Available research on puberty suppression and cross-sex hormone treatment is of such poor quality that no foundation exists for clinical decisions and informed consent.
• Clinicians are unable to determine which children and young people will have an enduring trans identity (the vast majority will, by progressing through puberty naturally, reconcile these feelings).
• The long-term impact of puberty suppression and cross-sex hormones on cognitive and psychosexual development is unknown and needs to be better understood.
• An unusual high number of children who believe they are transgender are neurodiverse, have psychiatric disorders or mental health issues. These realities need to be addressed in a comprehensive manner in addition to the feelings of gender incongruence.
• Initial research indicates that children presenting at gender clinics have experienced higher-than- usual levels of maternal / parental mental illness, exposure to domestic violence, emotional abuse and combined neglect or abuse. These need to be acknowledged with the support and therapies put in place for such children.
• A review of the first 124 cases at the NHS Gender Identity Development Service found over 25% had spent some time in care, and nearly 50% were living with only one parent.
• 73% of patients discharged between April 2018 and December 2022 were natal sex female.

Conclusions

1. For most young people, a medical pathway will 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 psychologically challenging problems.
2. While a considerable amount of research has been published in this field, systematic evidence reviews demonstrated very 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.

Response to the Cass report within the United Kingdom

In response to this review, the NHS has undertaken a carefully managed closure of the Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust, and is working on the establishment of new services reflecting a fundamentally different approach to the assessment, diagnosis, and treatment of children and young people with gender incongruence.

The release of the Cass-review was welcomed by both major parties in the UK parliament with health minister Victoria Atkins and shadow health spokesman Wes Streeting committing within days to its full implementation.

Dr Lade Smith CBE, President of the Royal College of Psychiatrists, has also welcomed the final report and its recommendations, stating: "The report highlights concern around the evidence base for the interventions that have been used in providing gender identity services in England. Children and young people in other spheres of healthcare routinely receive evidence-based treatment and rightly so. This should be the same for young people and children seeking support for their gender identity."

Situation in New Zealand

The response in New Zealand from the supposed experts in the area of gender medicine was to assess the Cass Review as harmful and irrelevant to New Zealand. This happened within less than a day and a half of its publication. PATHA, which has had a privileged relationship with Health NZ, published many still uncorrected misrepresentations about the Review including that it disregarded most of the available research. This and many other claims are untrue. Since 2012 New Zealand Gender Clinics have rejected the watchful waiting approach, despite many former and current leaders in the Gender Medicine Community emphasising the fact that the vast majority of children and young people grow out of their gender questioning phase by passing through natural puberty.

The 'model of care' currently used by Gender Diversity Services in New Zealand is based on the PATHA (Professional Association for Transgender Health Aotearoa) guidelines, which in turn are based upon the WPATH's (World Professional Association for Transgender Health) 'standards of care'. These have recently been discredited publicly after WPATH's leaked files were exposed by journalists Mia Hughes and Michael Schellenberger of Environmental Progress, revealing the experimental nature of the affirmative care model and the inability to gain informed consent from their young patients or their parents. Whilst this is a separate matter it is enormously relevant to our primary concern - our country's response to the Cass Review.

We are deeply concerned about the ongoing use of off-label medications given to our children to deter the natural process of puberty, without a proper understanding of the long-term physical, psychosexual and cognitive consequences.

In addition to the UK, Finland, Sweden, Norway, Denmark, Germany and the Netherlands, along with 23 states of the United States of America have now urgently overhauled their respective treatment models, following the emerging overwhelming evidence against the gender affirmation approach (social transitioning, puberty blocker use, cross-sex hormones, followed by radical surgery).

Lastly, it must be mentioned that the dramatic shift to the “affirmative care model” saw many clinicians in leadership roles in the UK and elsewhere unceremoniously removed from their positions of academic standing and professional influence. Needless to say, this is an area of medicine which attracts a high level of emotion and toxic responses from both sides of the debate. The Cass report addresses this by stating that in no other area of medicine are people so afraid to speak openly about such concerns, for fear of occupational and social consequences. We are adamant that this must stop.

For the sake of our tamariki and rangatahi struggling with gender identity along with other comorbidities, we appeal to the Ministers to follow the latest and best scientific evidence available and thereby avoid irreversible damage to our vulnerable young people through the experimental use of lifelong potent drugs and surgical procedures.

Thank you for your time and we look forward to your response.