Dutch expert warns on ‘blind adoption’ of puberty blockers

A Dutch expert on puberty blockers for children has warned that clinics around the world are “blindly adopting” this approach.

Detransitioner Keira Bell outside the Royal Courts of Justice in London after winning her 2020 case against the Tavistock gender clinic, which she argued should have been more cautious before approving puberty blockers for her when she was 16. Picture: EPA

A leading expert from the Dutch clinic which pioneered puberty blocker drugs for children distressed by unwanted sexual development has sounded the alarm about gender clinics around the world “blindly adopting” this approach without research.

Dutch clinical psychologist Thomas Steensma said the influential Amsterdam gender clinic did not know if its original “Dutch protocol” of puberty blockers followed by cross-sex hormones and surgery should be used with today’s different and poorly understood patient group.

“Little research has been done on treatment with puberty inhibitors and hormones in young people,” Dr Steensma told Dutch media. “That is why it is also seen as experimental.”

The Dutch protocol has inspired rapidly expanding youth gender clinics across the developed world, including in Australia, with the Royal Children’s Hospital in Melbourne campaigning in 2019 for extra money to become the first public children’s hospital in this country offering on-site transgender mastectomy as well as the hormonal treatments.

The 2018 RCH trans treatment guideline for minors — which relies on research by Dr Steensma and his Amsterdam colleagues — is used for medical interventions across Australia.

In a submission to the Senate inquiry into media diversity, RCH gender clinic director Michelle Telfer has defended her clinic’s treatment guideline following concerns reported in The Australian, saying it was “accepted as the current gold standard care”.

“What we have in Melbourne is one of the best evidence-informed, multidisciplinary clinical gender services and research teams in the world,” she said.

Video: Boston doctor Norman Spack championed blockers in the US

There is international concern about reports of a puzzling spike in teenage female patients — especially in the last 5-6 years — diagnosed with gender dysphoria seemingly out of the blue, lacking a documented childhood history of this distressing sense of a disconnect with birth sex.

The Amsterdam clinic began using puberty blockers in the 1990s and had a reputation for not allowing young people to start treatment unless it was clear they had suffered dysphoria since early childhood.

“Can our research from so long ago still be applied to the group of young people who are now reporting (to clinics),” Dr Steensma said. “And why are so many girls suddenly dissatisfied with their sex? That really needs to be investigated.”

His remarks in recent Dutch media coverage of Britain’s Tavistock clinic litigation over puberty blockers follow a similar warning last October in the journal Pediatrics from his Amsterdam clinic collaborator, the child and adolescent psychiatrist Annelou de Vries.

American endocrinologist Will Malone, a director of the gender clinic watchdog group the Society for Evidence Based Gender Medicine, said it was “highly significant” that these prominent clinicians had gone public with “serious concerns that the rest of the world is misusing the Dutch protocol”.

“The Dutch protocol, on which the entire ‘gender-affirmative’ treatment model for youth is based, explicitly disqualified any adolescents whose gender dysphoria emerged after the onset of puberty,” Dr Malone told The Australian.

“Such cases were considered to be much more likely to be ‘false positives’ — (meaning they) would later regret it.”

“The case of (detransitioner) Keira Bell (whose court victory against the Tavistock clinic is under appeal) illustrates this notion of a false positive that the Dutch clinicians worked hard to avoid.”

Britain’s NHS recently withdrew a claim that the effects of puberty blockers are “fully reversible”. Researchers and judges have lamented the lack of firm evidence about their effects on children https://t.co/lt3sLCPK72

— The Economist (@TheEconomist) February 19, 2021

Dr Malone said another risky departure from the more “controlled” Dutch approach was the affirmative model’s encouragement for children to “socially transition” before puberty.

Taking on opposite-sex names, hair, clothes and roles means a young child is more likely to go on to hormonal treatment and surgery, according to critics of the “child-led” affirmative approach.

Dr Malone said any clinician approving medicalised gender change for minors without a validated diagnosis of childhood dysphoria “should be aware that they are providing irreversible interventions with profound health consequences and risks without an evidence base.

“They are effectively conducting an unprecedented live experiment on youth, the results of which will not be known for probably 10 years or longer — since 10 years appears to be the average time to regret from older studies.”

Dr Steensma told the Dutch newspaper Algemeen Dagblad last month he did not agree with the English High Court ruling in the Tavistock case. The judges ruled that children under 16 would have “enormous difficulties” giving informed consent to “experimental” puberty blockers likely to lead to lifelong medicalisation.

Dr Steensma said: “We don’t suggest that hormone treatment is good for (all minors who seek it). We would never say that they are not good for anyone. We make an individual assessment for each case”.

“We are confronted with young people who are in enormous difficulties. For some of them they might even order medication on the internet or commit suicide (if denied treatment by the clinic).”

He said the Netherlands was “one of the few” countries with “ongoing research” into these medical interventions with children and adolescents who identify as transgender.

“But the rest of the world is blindly adopting our research … every doctor or psychologist who engages in transgender health care should feel obliged to check the results before and after.”

Michael Biggs’ exposure of the failings of the Tavistock's puberty blockers trial was first published by Transgender Trend in March 2019.
Here in part 5, Biggs analyses the long-delayed, final study results.
A must-read. https://t.co/Ck8jvY52lj

— TransgenderTrend (@Transgendertrd) December 19, 2020

Key Dutch studies also have their critics who claim the treatment approach is undermined by inadequate follow-up, missing data, and weak experimental design.

In her 2020 Pediatrics article, Dr de Vries warned that the Dutch protocol’s reported psychological benefits were based on treatment being given only to patients whose gender dysphoria had clearly been present “from early childhood on”.

She raised concerns about clinics today giving blockers to teenagers diagnosed with dysphoria after the onset of puberty, and more likely to regret treatment and “detransition”.

Dr Telfer told the Senate inquiry that reports in The Australian had exaggerated the risks of regret, and cited a Dutch protocol study claiming regret rates less than one per cent.

In 2019 RCH published an outline of plans for its own Trans20 research project, which lacks a comparison group given treatment different from the “gender affirmative” medicalised model.

RCH did not reply when asked for comment, and data showing the age of onset of gender dysphoria among its patients.

The Australian also sought comment from Dr Steensma, Dr de Vries, the gender clinicians group AusPATH and Dr Telfer.