Gender Expectations

The consequences of the media’s failure to tackle stories that don’t fit their acceptable narrative du jour can be more dangerous than we realise. For instance had the NZ Listener published my story on the risks associated with medicalising gender dysphoric teens in early 2021 as promised, one can only imagine the ensuing discussions and impact it might have had. Perhaps it would have given parents confidence to speak out, perhaps it might have given some confused young people pause for thought, perhaps it might have led to the erosion of confidence in this appalling experimental treatment. We will never know. Despite commissioning the story, the Listener chose to have it rewritten with a trans positive slant and published it late that year. I believe their reluctance to publish a more critical story had something to do with people in their orbit with transitioning teens. As we know by now, so often official resistance comes down to personal experience of friends and/or family. I think that’s what is known as suicidal empathy. The ‘be kind’ brigade’s failure to face reality has brutal consequences.

So below is the unedited original. All the concerns raised in subsequent reviews are here.

If anyone can understand what Keira Bell went through, it is Rachel*. Bell is the young woman who last year took the successful case against the British clinic that helped her transition from female to male as a teenager, a treatment she now says she was not mature enough to consent to (see sidebar on Michael Biggs). Rachel, a 23-year-old student in the South Island.is the same age as Bell and has gone through a similar experience.

On first meeting, Rachel presents as male. She has a deep voice, Adam’s apple, flat chest, and both facial and body hair. Not so long ago these characteristics helped her pass as male, something she had longed for since she was ten. 

Until then she had been happy being called a tomboy but that moniker became less acceptable as she grew older. So at ten she adopted a male name. By the time she was 13, suffering from depression, she was diagnosed as having gender identity disorder, now called gender dysphoria. Believing her gender identity did not match her sex, Rachel wanted to become male.

At 14 she was put on puberty blockers and less than a year later she began taking testosterone. The puberty blockers gave her menopausal symptoms such as hot flushes but testosterone proved to be the answer to her prayers. 

“I was delighted to be on this hormone and very pleased to be living as a male.”

It was even better when she changed schools. No one guessed she was born female. Before identifying as transgender, Rachel had come out as lesbian but while transitioning she wasn’t interested in dating. Her main focus was the transition process. In this she was supported by her parents who wanted the best for their distressed daughter. 

At 16 she had a double mastectomy and at 18 a full hysterectomy. A year later, while considering a phalloplasty (construction of a penis using tissue from a donor site such as the forearm), she began experiencing twinges of regret. 

“It wasn’t an overwhelming feeling. I think I was clinging to the sunk cost fallacy - I have done all this so I may as well continue.”

Nevertheless the feelings of discomfort continued. “I started to realise I would never be male. Female socialisation is with me. I began to realise being male isn’t just a feeling.”

At 22 she was swamped by profound regret and was, for a short time, suicidal. 

“I didn’t know how to move forward when I realised I had made a mistake. 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.’”

Now 23, Rachel admits her detransitioning is still a work in progress. People tend to see her as male despite the fact she is on estrogen now and will be for the rest of her life and that she regards herself as female. 

“I am probably not one hundred percent okay with being female but I don’t buy the narrative that I was born in a wrong body. I genuinely don’t believe that with all my heart.”

Overseas, Rachel’s experience has been echoed by many young women. In fact the growing number of young girls identifying as transgender, often in clusters among social groups, has been dubbed ‘rapid onset gender dysphoria’ and a form of social contagion by one researcher* and examined by American journalist Abigail Shrier in her book Irreversible Damage: the Transgender Craze Seducing Our Daughters though it must be said both experienced considerable pushback from gender activists.  In the United Kingdom young people referred for gender treatment increased by over 4000 percent from 2008-18. 

Celebrity transmale transitioners include Elliot Page (formerly Ellen Page of Juno fame), Chaz Bono (formerly Chastity Bono, daughter of Sonny and Cher) and Shiloh Jolie-Pitt, child of Angelina Jolie and Brad Pitt. 

To date New Zealand has not seen the gender treatment spikes observed overseas but the number of people referred for surgery has increased by over 160 percent between October 2018 and 30 September 2020.  Also a study of people referred to the Wellington Endocrine Service from 1990 to the end of 2016 noted an increase for both male-to-female and female-to-male referrals. Before 1999 less than 10 people a year identifying as transgender attended the clinic. Between 2000-2007 between eight and 15 people a year identifying as transgender attended. By 2016 that figure was 92 people.

Surgery for transitioning from female to male may involve facial masculinisation, mastectomy, hysterectomy and a phalloplasty. Surgery for male to female may involve vaginoplasty (creation of a vagina using penile tissue), breast augmentation, orchiectomy (testicle removal), facial feminization surgery, reduction thyrochondroplasty (tracheal shave or reduction of Adam’s apple), and voice feminization surgery. 

However the vast majority of male-born transgender people keep their genitals and are fully male-bodied. Data is scarce but 2019 American stats indicate only 5-13 percent of transwomen have genital surgery while 8-25 percent of transmen have chest surgery and 14 percent a hysterectomy.

New Zealand funds up to 14 sex reassignment operations a year. Pre-Covid, Thailand performed the most sex reassignment operations in the world followed by Iran where government funded surgery is a response to homosexuality, which is illegal and can be punishable by death.

Approximately 1.2 percent of adolescents in New Zealand identify as transgender according to the Youth 12 survey of 8500 secondary school students taken in 2012. The survey is part of a long-running study with a 70 to 80 percent response rate. The results for the latest Youth 19 study have yet to be officially released. 

However Rachel was not part of a social group where being trans was cool and she knew few gay or trans people. She discovered the trans community online and says she spent hours watching youtube videos and connecting with other trans peers.

“I think for me becoming trans was an expression of my internalised misogyny. When I came out as lesbian I was proud but I still carried a lot of shame. I was way more visible as a butch woman than I was living as a man.”

In October two websites expressing concern about the medicalisation of transgender identifying children were launched within a fortnight of one another. Transkidsnz and Fully Informed.NZ are not linked. Transkidsnz explores ‘the myths and the facts’ of the transgender movement while Fully Informed (FI) questions the Ministry of Health’s policy of gender affirmation and medication. 

Transkidsnz did not respond to the Listener’s request for an interview. Fully Informed did. They describe themselves as “a group of people concerned about the legality and long-term impacts of prescribing puberty blockers to children. Some of us are parents. We have several decades of experience in policy, medicine, research, and education.”

Spokesperson, Wellington IT consultant and former policy analyst, Simon Tegg has a history of interest in environmental and leftist activism. He had flatted with trans and nonbinary people but never questioned medical interventions/the transgenger movement deeply. When he realised that children are now taught that they could be “born in the wrong body” he decided to inform himself. “Kids are often troubled for all kinds of reasons.”

During this exploration he met others similarly concerned and together they founded Fully Informed. On its website FI demands the Ministry of Health remove descriptions of puberty blockers as “safe and fully reversible” and that medical professionals provide all relevant information on these drugs to parents, including the risk of negative impacts on cognitive function.

At present the Ministry of Health website states “Blockers are a safe and fully reversible medicine that may be used from early puberty to later adolescence to help ease distress and allow time to fully explore gender health options.”

Gonadotropin-Releasing Hormone Agonists (GnRHa) have only been around since the 1980s and used to treat gender dysphoria since the 90s in the Netherlands. Before that they were used to treat adults with endometriosis, prostate cancer, breast cancer, children with precocious puberty and to chemically castrate sex offenders. When used on adolescents with gender dysphoria, GnRHa block the release of sex hormones thus suppressing normal pubertal development. 

However, there are no high quality, long term studies on the physical or psychological impacts of these drugs on adolescents. Lack of studies does not mean there is no risk. FI says when studies include controls, they show no benefits from blockers and highlight potential negative impacts on cognitive function, increased suicidal behaviour and worsening body image, particularly in females.

Children 16 years and over are considered legal adults. Prior to that age, international guidelines require parental consent before prescribing blockers. FI says legally that consent must be fully informed as specified in Right 6 of the Health and Disability Commissioner (Code of Health and Disability Services Consumers’ Rights) Regulations 1996 otherwise medical practitioners could be found guilty of professional misconduct. Exemplar consent forms published by the University of Waikato do raise concerns about bone density, fertility and sexual desire but not the risks to cognitive development. 

Similar concerns have been expressed overseas. In Sweden referrals to gender clinics increased by 1500 per cent from 2012-2018 but fell by 65 percent in 2019 after experts called for a governmental review of clinical protocols and critical media such as the Swedish documentary The Trans Train featuring detransitioners were aired.

In Britain the National Health Service website formerly stated puberty blockers were “fully reversible” but recently that advice changed to “little is known about the long-term side effects of hormone or puberty blockers in children with gender dysphoria.” The website goes on to say that also unknown are the psychological effects of reversing treatment, the effect of hormone blockers on the development of the teenage brain or children’s bones and the effect of long-term cross-sex hormones. The NHS is currently reviewing the evidence on the use of cross-sex hormones by the Tavistock Gender Identity Service.

In the Keira Bell case (see story on Prof Michael Biggs), the court ruled that children under 16 should not be given puberty blockers. Doctors must now obtain a “best interests” court order to administer this treatment. Tavistock has since suspended treatment pending an appeal against the ruling, a ruling that may influence courts around the world engaged in similar litigation. The service has been granted permission to appeal against the High Court ruling.

Watching the Tavistock case with interest here is Deborah*, the Canterbury mother of a 17-year-old girl wishing to transition. As a child, Josie* showed no signs of wanting to be a boy though she was socially awkward and preferred spending time with adults. After the family moved, Josie changed schools. She began spending more time on the internet than usual and not longer afterwards announced she was gender fluid. Deborah was then informed by the school that Josie had begun cutting herself and wanted to be a boy. When she was 15 she was diagnosed as being on the autistic spectrum. 

Josie received regular counselling by a psychologist and was eventually referred to a psychiatrist who suggested Josie try puberty blockers assuring them they were not harmful and reversible. Deborah felt uneasy about this step and since her daughter was not yet 16, was able to decline the treatment.

But when Josie turned 16, she went on puberty blockers and said she found them helpful. However Deborah witnessed her daughter experiencing hot flushes, headaches and fatigue. She no longer has the right to be informed about her daughter’s medication and worries that the next step is testosterone. She wrote to Josie’s doctor expressing concern but was advised there was little she could do except stand back and support her daughter as she made her own mistakes in life. 

“I think part of the problem now is that she mostly socialises online. I don’t care how she identifies but I do care about permanent harm.”

Deborah wishes the medical profession had embarked on a deeper exploration of her daughter’s psychological state and taken into consideration her autism before medicating her. For instance she remembers her daughter suffered jeers from other children calling her a lesbian at primary school.

“Also not one professional told Josie that it’s normal to hate your body when you go through puberty.”

In 2018 neuroscientist Dr Debra Soh, whose book The End of Gender was featured in the Listener, October 17-23, expressed concern in an article about the rush to label and medicate gender non-conforming children based on her own experience as a gender non-conforming child. Pre-puberty all her friends had been boys and her mode of play typically rough-and-tumble. She even insisted on standing up to use the toilet. When puberty arrived she was relieved her body didn’t undergo too many physical changes. 

“Then something bizarre happened - I reached my late teens and for the first time of my own volition I fancied putting on a dress. The idea of appearing feminine no longer repulsed me so I grew my hair long (she had previously shaved it off) and began carrying a purse.”

She says research shows most gender dysphoric children outgrow their dysphoria during adolescence. Before the introduction of puberty blockers, around 80 percent of young children with gender dysphoria would grow out of it naturally, typically becoming gay, lesbian or bisexual adults. Some, like Soh, would grow up to be straight adults. Research also shows that up to three to six times more autistic children identify as trans or gender diverse than non-autistic children. A small proportion of trans kids with persistant dysphoria would benefit from medical intervention, but predicting these ideal candidates is tricky.

“Outgrowing my discomfort resulted from the realization that gender does not need to be binary. To this day, I still feel that I am more masculine than most natal females, but also much more feminine than most natal males. We can have the best of both worlds.”

But New Zealand has adopted the gender affirmative approach. The “Guidelines for Gender Affirming Healthcare” for gender diverse, transgender children, young people and adults in Aoteaora NZ published by the Transgender Health Research Lab in 2018 state that “withholding gender affirming treatment is not considered a neutral option, as this may cause or exacerbate any gender dysphoria or mental health problems.” It also states that “puberty blockers are considered to be fully reversible and allow the adolescent time prior to making a decision on starting hormone therapy.” 

Although the guidelines are only two years old, the chair of the New Zealand Medical Association Dr Kate Baddock believes that new information and concerns raised by FI need to be addressed and debated in the community. 

“The affirming nature of the teen’s identity may not be firmly set and there is some value in considering whether further exploration should be undertaken.” 

As a GP faced with a gender questioning adolescent, she had previously referred the adolescent to an endocrinologist but now she accepts there may be a case for referring them to a psychologist or psychiatrist first. As for the “safe and reversible” puberty blockers, Baddock says there are side-effects with all treatments and puberty blockers are a significant intervention. 

“Depending on the child and the age they present, they may or may not be mature enough to make this decision. The whole issue needs wider discussion.”

The president of the New Zealand College of Clinical Psychologists Dr Malcom Stewart is also not convinced puberty blockers are safe and reversible. “I believe there is evidence of subtle changes in their neurological development that may have a lasting effect. Everything comes with a risk.There is the risk that people may change their minds and things may not be entirely reversible physically or socially.”

He does not believe being transgender is innate “because much of human experience is much more a balance of the two.” But equally he is aware there is a risk that a child who is not supported in the gender they identify with may also be harmed though he admits his knowledge is largely anecdotal. 

While Stewart is not opposed to the gender affirming approach, he recommends supported watchful waiting. Stewart says puberty blockers may help a young person navigate this phase of their life well but they should be used with careful consideration of the psychosocial factors.The younger the child, the more important is the need for good psychological assessment and assistance.

Christchurch youth health advocate Dame Sue Bagshaw has been prescribing GnRHa since 2000 though at that time only one or two people a year presented with gender dysphoria. Now she sees about 100 people a year. 

She says puberty blockers are reversible though she acknowledges that no long term quality studies prove this and few of her patients have chosen to cease medication and return to their biological sex. 

She hopes a summer research project she is co-supervising on the use of GnRHas in gender transition adolescents will add to the body of knowledge. The project will review the literature on GnRHa for under 20-year-olds and develop a tool to aid the audit of patient notes to assess the outcomes of gender diverse clients on GnRHa. Her clinic is not able to follow up clients before 2012 when many records were lost in the quakes.

Bagshaw believes being transgender is innate. She finds the easiest people to diagnose are adolescents who say they’ve known they were different since they were three or four. Others are more difficult. She acknowledges there are fashion trends, “almost like an identity young people are trying on as part of their ‘who am I?’ journey. Unless they have the classic transgender history, I have to try to delay irreversible damage.”

She says she does this by investigating other possible underlying psychological reasons for the adolescent’s gender dysphoria as well as helping them become an adult (jobs, training etc). Yet at the same time Bagshaw admits almost all her clients are put on puberty blockers and almost all go on to have hormone treatment. 

In Auckland Dr Jamie Speeden, a child and adolescent psychiatrist and paediatrician, is on the Gender Dysphoria Steering group for the Royal Australian and New Zealand College of Psychiatrists (RANZCP). The RANZCP is conducting a review of their position statement 'recognising and addressing the mental health needs of the LGBTIQ+ population' after heated debates from both sides on what constitutes appropriate treatment.

In September 2019 the RANZCP also removed a sentence supporting the gender affirmation approach as practiced by the Royal Children’s Hospital Melbourne to recommending “evidence-based treatment guidelines.”

In August 2020 the president of the National Association of Practising Psychiatrists in Australia warned the RANZCP to be “extremely careful” before endorsing so-called “gender-affirming” hormonal treatment and surgery for minors.

However Speeden supports the gender affirmative model and rejects the notion of rapid onset gender dysphoria, arguing that these children have always been there. He says a 2017 study showed there is some evidence that being trans is innate. What has changed is the community’s acceptance of diversity and this has encouraged the increased visibility of transgender youth. Puberty blockers give those young people time to work out their identity and assist those distraught to the point of being suicidal (NB: SUBS: that breather argument has been found to have no substance in the Tavistock case since almost all individuals put on puberty blockers go on to cross-sex hormones - I mention this in the Biggs story, should I mention it here again?). He says the Youth 12 survey showed one in five identifying as trans or gender fluid had attempted suicide in the last year, however trans people are not likely to show up in suicide statistics since their gender is not known or disclosed.

 

Critics such as Fully Informed say similar levels of suicidal behaviour among LGB youth indicate bullying is the more likely cause, not lack of puberty blockers. Also abuse and mental health may precede a gender identity crisis and that the background of a general youth mental health crisis must be taken into consideration.

Tegg is also not convinced by the Counting Ourselves survey, a 2018 anonymous community-led health survey for trans and non-binary people, that implied a lack of access to hormones and blockers is a cause of poor mental health.

“The more likely explanation is that young lesbians and rape survivors are transitioning to escape abuse. Which might ‘work’ but is hardly ethical. A neoliberal endgame. The child feels powerless to do anything about bullying and society and instead changes their body with drugs to fit expectations, adopting an ideology that celebrates their medicalisation along the way.”

Nevertheless Speeden asks “How many young people would decide to go through all the stigma of being transgender affecting their education, employment, relationships? None of this is easy when you are transgender. Even accessing normal healthcare is difficult. 

“Going on hormones requires an injection every three months or an implant. So you are putting yourself through some pain. It is uncommon for them to pause and revert to their birth assigned gender though it does happen.”

 He says the number of young people detransitioning is very small and usually not a problem since most people do not have surgery until their 20s. 

The whole issue of the risk posed by puberty blockers has been overblown says the national coordinator Ahi Wi-Hongi of transgender organisation Gender Minorities Aotearoa. Every medical intervention comes with risk. Puberty blockers are similar to contraceptives in that both prevent normal bodily processes. Once people cease taking this medication, those processes will resume. (SUBS:  again Tavistock showed few people ceased taking puberty blockers, most went on to cross-sex hormones. Raised by Biggs and Bagshaw. Not sure whether to let this go unchallenged) Also people may stop taking hormones and still be trans. 

Wi-Hongi said trans people have no desire to get into the debate likening it to asking a black person to debate a white supremacist. 

“The white supremacist might say they’re interested in preserving their culture and that it is okay to be white. Many people might not realise the real agenda underneath those statements.

“It’s very common for anti-trans campaigners to claim to be feminists and interested in women’s rights but I don’t see them campaigning for women on welfare, the gender pay gap and sexual abuse. Their only interest is to stop transwomen from accessing houses, birth certificates, health and recreation. We come from a human rights perspective.”

Wi-Hongi felt confident that New Zealand had sufficient laws, policies and protocols in place to ensure the drugs prescribed to trans teens are safe and reversible. 

Speak Up for Women formed in 2018 in response to the Births Deaths Marriages Relationships Registration Bill that included provision for changing the sex recorded on one’s birth certificate via a one-step statutory declaration. They say they formed out of necessity since no other women’s group appeared to be examining the implication of this legal change on women’s rights. However within their group are women who have been involved in a wide range of issues such as setting up the first women’s refuges, the Ministry of Women’s Affairs (now called the Ministry for Women), campaigning for abortion law reform and gender pay equity.

Says spokesperson Ani O’Brien: “Gender activist groups disingenuously claim we are engaged in a meaningless attack on their rights, but the truth is we are doing nothing but defending the bedrock that serves as a foundation on which all other women’s rights rest.”

She says that without the ability to define women as a sex class with significant common experiences, women are not able to address other important issues such as statistics on violence against women. 

“Even official government statistics have been compromised by allowing male crimes to be recorded as female crimes. It also allows these male prisoners to be housed in women’s prisons where inevitably they present a risk to the female inmates.

 

“The issue of what a woman is - and the abuse that women receive for asserting that a man cannot decide to become one - is an existential threat to feminism and women’s rights movements. If anyone can be a woman then why do our rights matter? If anyone can be a woman how do we address the common experiences unique to the biological sex class of women? “

The world's first openly transgender mayor and Member of Parliament, Georgina Beyer, now 63, began hormone treatment at 16 and reassignment surgery at 25. That delay was largely due to the lack of a public system that could assist her at the time. “To put it bluntly I had to sell my arse to buy my fanny.”

Given her own experience she says it would be hypocritical of her to advocate raising the age of consent but she says all interventions require proper oversight. “This profound life-changing stuff needs to be done with scrutiny and duty of care.”

She is concerned that adults are making decisions for young people who have barely started life and worried that the people involved in the policy consultation process come from a transactivist viewpoint. “Policy decisions need to be taken beyond people who have a stake in the outcome. I question the qualifications some of the people involved have to inform policy makers. It wouldn’t hurt to review these things.”

Beyer warns that medical professionals who fail to take proper care may have their actions thrown back in their faces at a later date.

Yet, despite the Tavistock case and concerns expressed by some medical professionals, there are families with transitioning children who say puberty blockers have been beneficial.

In Auckland Christine’s* daughter has insisted she was a boy from about age three but it wasn’t until the primary school contacted her when she was six to say her daughter wanted to use the boy’s toilets, that she and husband began the trans journey with Sam*. This led to numerous appointments with psychologists and other medical professionals. Christine also spoke to transmen about their experience as a child and said they were able to express feelings her child had been unable to put into words. Sam socially transitioned from the age of seven, using the boy’s toilets and male pronouns. Both the school and the children were fine about it, says Christine. 

It was only when Sam began to go through puberty that he became distressed at the thought of having breasts or menstruating. At 12 he was put on puberty blockers and, now 13, he is much happier. Christine has followed the Tavistock case and agrees any medication given to children is a concern “but in our journey the upsides outweigh the downsides. Also every professional we dealt with was in favour of slowing things down and waiting as long as possible.

“Before Sam came along I thought trans kids were just kids rebelling but for him it was so innate and the feelings seemed to originate at a deeper cellular level.

“Just because one or two young people regret the actions they took to become trans doesn’t mean you can discount the entire community. Also I think clinicians should be making the call, not judges as in the Tavistock case.”

Studies of desistance are still in their infancy and like much research and debate in this arena, highly controversial. In the UK, James Caspian, a psychotherapist who specialises in working with transgender people, is taking Bath Spa University to the European Court of Human Rights over the university’s refusal to allow him to research gender de-transition – for fear of being judged ‘politically incorrect.’

This is one reason why Rachel is reluctant to give her name or even say where she lives. However she doesn’t want to come across as a victim. Losing the ability to give birth doesn’t bother her since she never wanted children. Losing her breasts is another story “but I’ll just have to deal with it.” She also applauds the local surgeon who refused to give her a mastectomy at 16 because she was too young. Rachel was so determined to proceed she went overseas for the operation. 

Yet only a few years later she would regard trans ideology as regressive. Now she asks why should boys who like pink and playing with dolls be female and girls who love trucks and rough play be boys? Isn’t that just a return to obsolete sex role stereotypes?

Despite the undeniable influence of social media on her transgender journey, Rachel says it also helped her find her current tribe - “and it’s beautiful.” And having found it, she’s given up completely on social media. 

 *Not her real name. Rachel requested anonymity fearing potential bullying, career consequences and public denigration. For the parents and children it was requested to project the anonymity of their child.