Puberty Blockers: Part Two

Endocrine Society and the case for Puberty Blockers.

For my second post I will look at an article which, on balance,  advocates for an affirmative approach for children/teenagers with Gender Dysphoria. Endocrine News

Historically the treatment, for children, was to watch and wait.  The medical consensus indicated that the majority resolve gender identity issues, following puberty. In the light of this research  the treatment protocol was to defer medical intervention.   An overview of some of the research, advocating for this approach,  is contained in this article:  Critique of the American Association of Paediatrics.

Over the last decade, however, the sector has moved to an affirmative model of care which holds that discordance between biological sex and gender identity is a biologically based phenomenon. The condition of Gender Dysphoria is no longer regarded as a psychological phenomenon. We are told  one can be “born in the wrong body”  and the phrase “assigned fe/male at birth” is in widespread use, even by medical practitioners. This ideological shift  underpins a revision  to how we treat children presenting with issues of Gender Identity. Medical intervention, according to this theory, is merely confirming a biological fact. This necessitates aligning the physical body to an, assumed, opposite sex brain.

Despite the overall thrust in favour of early intervention the article does  raise some interesting ethical dilemmas and  makes some, albeit limited, reference to opposing clinical views.   The language used, however, talks of “biological gender” rather than “biological sex” which serves to reinforce belief in the biological underpinning for the condition. 👇

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Notice also the sleight of hand that presents puberty blockers as a “delay” and a device to “buy time”.   {Later on in the piece it seems  clear that we are not simply delaying or pausing puberty, watch the language shift}2F2853F7-D2AC-44F6-9DD6-0B5A6B7626BBNorman Spack was the person involved in the high profile, early transition, of the child of, Mermaids founder Susie Green.  The last sentence is indicative of the number clinicians feeling wary, or ill-equipped to practice in this field.  The effect of this reluctance, arguably, leaves the discipline dominated by those with a particular zeal to work in this area. Are those clinicians more likely to adhere to biological theories of its aetiology? Are the treatments advocated then more likely to  follow an affirmative pathway? Most practitioners I encounter, who work in this field, do seem to subscribe to a “born in the wrong body” narrative which, I would contest,  deeply influences their approach to practice. Do we have enough variety of approaches in the  Gender Identity specialists, working with Gender Dysphoric children /teens?

So what vidence is there for the  claims of a biological origin for “transgenderism” ? There is research showing a much higher incidence of transsexuals in identical twins than in fraternal twins. 👇 The figure of 40% has been critiqued, but do we even need to cast doubt on this figure? Wouldn’t we expect it to be at least closer to 100% if the cause is biological & not cultural/ environmental? 

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The research relies on the, hugely contested, notion of female brain versus male brain. The article below raises some questions about the nature of the research, the lack of  consistent outcomes and limited understanding of the effects of cross-sex hormones on the brain, or the impact of neuroplasticity. I think it is a fair conclusion to say the jury is still out  but here is one study: The Transgender Brain . 

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Clearly there are divergent views but irrespective of those espousing the idea of conflicting “brain sex” the fact remains  we do not have a diagnostic tool to “prove”  anyone, presenting with Gender Dysphoria, has a biological condition. In the absence of definitive, diagnostic criteria are we confident that early intervention is the best course of action?   Especially in the context of historically high rates of desistance from a trans-identity? Ken Zucker has worked in this field for decades and is also quoted in the article.

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Not only are we looking at an average of 80% desistance rates there is also a high correlation between those that desist but many will mature  into gay males or lesbians. Are we being cautious enough?  The level of  desistance rates  is often disputed but it has been a consistent finding that the majority desisted even if you reject the figure of 80%. There are legitimate criticisms of the data on persistence /desistance. Loss to follow up is one.  Patients who cease to engage with service providers may be desisters or, as is argued, they may have moved to other providers.  De-transitioners are pretty consistent in saying they would not return to the very professionals who were complicit in their medicalisation/surgery so this has to form at least part of the “loss to follow-up” population. I have covered some of these critiques in part one.  Here a pro-affirmation practitioner raises caution about a too swift diagnosis even though, as they make clear, they are proponent of a “hard-wired” transgender identity. 

7DDABD2C-893C-453D-B03D-AC0E65A36B63726A78C5-CE14-4D4D-AE2A-940D9AD6B80EIt is clear, to me, this is a contentious area and furthermore that there is no consensus on a biological basis for Gender Dysphoria. However, if as I contend, the “hard-wired” belief is  widely accepted by the sector  it will have an impact on clinical approaches. It follows that identifying this population early is believed to  allow swift intervention to ameliorate present, or anticipated, distress.  It appears to be a widely, and fervently, held,  view, that it is necessary to block puberty and administer cross sex hormones at ever younger ages. A more recently advanced justification, in this paper, is that blocking puberty reduces the need for later surgery and, makes it easy for the Transgender child to conform to norms for their target sex.

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The move to earlier medicalisation, for gender dysphoric children is a) conditional on a belief it is biologically based b) that we can identify this population with a degree of accuracy. I reiterate: we currently do not have a reliable, medical method of testing any biological markers for innate gender /sex incongruence.   In the UK we can start puberty blocking at age 12.  Spack advocates for age 10-12 for girls and 12-14 for boys.  This prevents development along expected lines so the idea is that we halt masculinisation in boys and feminising effects in females.  We halt female breast development and promote greater height and, do the opposite to males. Yet the very phrase “puberty-blockers” gives an impression of a targeted intervention when we actually don’t know what other impact these drugs  have.

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Notice above that we are not talking about a “delay” or a “pause” we are now talking about “prevent pubertal progression”.  That is a change of language that matters.  If we are right we are preventing something that is undesirable. If we are wrong…..

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The article continues and references the , by now well documented, change in the sex ratios in those presenting with Gender Dysphoria.  This shift cannot be explained by an underlying biological basis unless argued, as it is, that we are now more accepting of Transgender communities which enables more girls to come out. As many of us  have highlighted there does seem to be a dearth of middle-aged women suddenly discovering their authentic selves.   I have not seen any research which questions why there are so many older males and an almost complete absence of late transitioning in the female sex.   I am also not sure that Butch lesbians would concur that there is widespread acceptance of “masculine” women as is argued below.

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What we are talking about below is removal of the testes or ovaries, womb, inversion of the penis and creation of a facsimile or neo-vagina. The proponents of this tend to use medical or euphemistic language to soften what they are actually undertaking.  Hence we have the prevalence of “top surgery” crowd funders which do not use the terminology of “double mastectomy”.

50F3102B-9A92-472C-9A99-6F7AEAE78937 Spack’s own policy is that patients must have the support of “both custodial parents”.  That phrase jumped out because we are starting to see cases of parental disagreement and the non-custodial parent is omitted from this statement. He also states that there must be a referral letter that confirms there is no other co-morbidities.  I know from my own reading that this is not the case with many of the cases I have followed.  I have seen diagnosis of Border Line Personality Disorder and Schizophrenia described as “coincidental” to the Gender Dysphoria.  This is often accompanied with a demand to respect the bodily autonomy of those with mental health conditions. Here is a letter sent by Dr James Barret to the London Review of books which confirms that mental health conditions, of a most serious nature, are not a barrier to treatment:

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Norman Spack , on the other hand, states that severe psychopathology must be ruled out before commencing treatment:

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Below we are told that there is no “litmus test before Tanner 2 puberty”.  Also it is also revealed that those who go onto puberty blockers don’t desist.  I have seen Dutch research that confirm a 100%, of those on puberty blockers,  don’t reconcile to their biological sex, and do go onto cross-sex hormones.  Here is that  Dutch Study

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GnRH analogues appear to be pretty fast acting.  What this means for these adolescents is that they are left in a “prepubertal” state and out of step with their cohort.  Again we are told they are “reversible” but of course all of that is a moot point if, as the Dutch study illustrates, most don’t desist once they have embarked on medical intervention.

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Here is a clear statement that the price that will be paid is “infertility”.   I have lost count of the number of people who have , not always politely, accused me of lying about this and here we have it confirmed.  Of course it is difficult to have a conversation with a 12 year old about infertility and for them to understand what they are giving up.  Ironically there was , quite rightly, outrage from the Trans Community, at those countries that made sterilisation a pre-condition for their treatment.  Yet on this type of sterilisation transactivists have been resolutely silent. (Though there are adult transsexuals who have expressed concern about youth medicalisation).

4696C6A3-58C1-484B-9004-BF36531D9D607AC75242-C3DE-4BEE-91CB-9ADE1C9943E5Here is a risk benefit analysis which again promotes the benefits of earlier intervention.  Yes. Cancer is a risk.  Yet we can simply surgically remove the at risk organs.  And of course appropriately sized breasts has to be a priority!

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It is true that puberty blockers have been used for precocious puberty for decades. This research mainly covers girls who are more prone to early onset puberty or, perhaps, more likely to be medicalised. Even whilst claiming the safety of puberty blockers for this group of patients it is admitted that we are still not clear if the same applies to “transgender” patients.

1BD724F1-4676-401E-AC29-EBEDB23F9836Furthermore it is also not quite true that there are no dissenting voices about the safety of the treatment.  Adverse outcomes: Puberty Blockers.  

Also note that this patient group have a diagnosed condition.  We do not have a diagnostic tool for the transgender patient group.  Furthermore , there is a dearth of males in the first cohort so limited research on this group.

The article concludes with this statement.  I am not reassured. Not at all.

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