Thank you for your feedback, Eduardo. I wrote this article about a year ago when I still wondered if an ethical trial of puberty blockers might be feasible and if one might somehow settle the puberty blocker issue once and for all. How naïve was that!
My position now is that puberty blockers for the treatment of gender distress are unethical. Full stop. Mainly because they prevent normal puberty, which is what turns children into adults. It hadn’t really occurred to me that if minors were puberty blocked, reaching the magic age of 16 (when they can consent to cross sex hormones) would be immaterial as their executive functioning would not have matured in the same way a non-blocked young person’s would have. Blocked children at 16 would be no more capable of making life altering decisions involving extreme body modification than they had been at 11 or 12.
I think I used to wonder if cross sex hormones could produce a simulacrum of puberty that was sufficiently similar to normal puberty for it to make no difference to cognitive and emotional development. Nowadays I very much doubt if that is likely.
Another highly important point to highlight is that the 11 persistence studies conducted before the experiments with puberty blockers showed that all or the vast majority of participants abandoned the illusion of changing sex after going through endogenous puberty.
When comparing the results of these 11 studies, a very clear difference emerges between those conducted before the year 2000 and those conducted afterward: in the 7 pre-2000 studies, among 148 participants, 8 persisted; in the 4 post-2000 studies, among 345 participants, 88 persisted. In other words, it went from 1 in 19 to 1 in 4. It is very reasonable to deduce that as “gender medicine” expanded, its negative impact grew, capturing more and more patients with gender dysphoria in the illusion of an —impossible— “sex change” as a solution to their distress.
Puberty blockers not only block puberty but also block the resolution of gender dysphoria. This is why they inevitably lead to hormones and surgeries, and afterward the percentage of those who die by suicide increases, and the more years that pass after medicalization, the higher the rate of patients who detransition.
Thanks for that useful analysis. It certainly makes sense that the decline in desistance after 2000 could be explained by the advent of puberty blocker treatment in the 90s
This is a great article. I'll just highlight a few ideas and add a few nuances.
• The influence of trust in the doctor-patient relationship is central to the whole issue of the medicalization of gender dysphoria. From isolated cases in the past to the current epidemic, the ultimate explanation for this whole scandal lies in the erroneous and messianic belief that it is possible to change sex, a belief set in motion and sustained by excessively arrogant and conceited researchers who have sold people struggling—for various reasons—with their gender a magic bullet as ineffective as it is poisonous.
• When we talk about low-quality studies with small sample sizes, poor design, and risk of bias, we're referring to studies like the one that proponents of the medicalization of gender dysphoria tried to hide and whose results they lied about, as I explain and show here:
• When analyzing the effects of puberty blocking, it's crucial to understand that its irreversibility guarantees the use of cross-sex hormones and, in many cases, mutilating surgeries. The risks include: infertility, lack of sexual function (anorgasmia), pelvic floor dysfunction, increased risk of breast cancer, weight gain, symptoms of premature menopause, cardiovascular complications, type 2 diabetes, and a possible reduction in life expectancy.
In summary: the promotion and use of puberty blockers in cases of gender dysphoria is absolutely contrary to medical ethics.
Thank you, Isobel, for this excellent critique of the limits of capacity for children to give any sort of consent at all, let alone informed consent to procedures and treatments that will cause iatrogenic harms to both their bodies and their minds.
I really appreciated this sentence because it is a good example of how the system operates in real life: "For instance, I have observed instances of patients with full blown dementia signing surgical consent forms for hip-fracture surgery." A few years ago, a close relative had a severe mental health crisis which necessitated his admittance to an inpatient mental health facility. He was admitted under an informed consent protocol, which I later challenged after he was safely admitted, and I was told that "this makes it easier for us because otherwise we have to get the police involved and do a lot more paperwork"!
And "There is a difference between asking someone, “Do you understand?” and receiving a “Yes” response and asking someone to explain, in their own words, what you have just told them." In my professional work as a midwife, I was very aware of the difference between women agreeing to something and women understanding what they were agreeing to. For example, unless there is a discussion first, women do not realise that agreeing to an induction of labour includes having a cannula inserted, having continuous CTG monitoring and giving up their hopes of having a water birth.
It is not possible to have an informed consent decision about issues that children lack the capacity to contemplate or understand. How do you talk about losing the prospect of never having a pleasurable sex life or an orgasm with a 14-year-old who never even started puberty?
Personally, the most frightening aspect of "gender affirming care" for children/teens is missing out on that crucial brain maturation that is vital for the development of our frontal lobe/executive functioning that distinguishes adults from children. https://lucyleader.substack.com/p/time-critical-brain-development
Thanks Robin. It looks like you and I are pretty much on the same page when it comes to the safeguarding capacities of so-called “informed consent” - pretty much non-existent I’d say! Patients have, at least up until now, had a lot of trust in the caring professions. They assume we’re all guided by beneficence and non-maleficence and proper scientific enquiry. It worries me that activist clinicians are abusing that trust by prioritising ideology over patient safety. This can only have a detrimental effect on trust in medicine as a whole and this will be bad for everyone, not just gender clinicians and paediatric endocrinologists.
Thank you for your feedback, Eduardo. I wrote this article about a year ago when I still wondered if an ethical trial of puberty blockers might be feasible and if one might somehow settle the puberty blocker issue once and for all. How naïve was that!
My position now is that puberty blockers for the treatment of gender distress are unethical. Full stop. Mainly because they prevent normal puberty, which is what turns children into adults. It hadn’t really occurred to me that if minors were puberty blocked, reaching the magic age of 16 (when they can consent to cross sex hormones) would be immaterial as their executive functioning would not have matured in the same way a non-blocked young person’s would have. Blocked children at 16 would be no more capable of making life altering decisions involving extreme body modification than they had been at 11 or 12.
I think I used to wonder if cross sex hormones could produce a simulacrum of puberty that was sufficiently similar to normal puberty for it to make no difference to cognitive and emotional development. Nowadays I very much doubt if that is likely.
Another highly important point to highlight is that the 11 persistence studies conducted before the experiments with puberty blockers showed that all or the vast majority of participants abandoned the illusion of changing sex after going through endogenous puberty.
Regarding those studies, I have them listed and I show their results here: https://cabrerae.substack.com/p/trans-identity-fixed-or-transient
When comparing the results of these 11 studies, a very clear difference emerges between those conducted before the year 2000 and those conducted afterward: in the 7 pre-2000 studies, among 148 participants, 8 persisted; in the 4 post-2000 studies, among 345 participants, 88 persisted. In other words, it went from 1 in 19 to 1 in 4. It is very reasonable to deduce that as “gender medicine” expanded, its negative impact grew, capturing more and more patients with gender dysphoria in the illusion of an —impossible— “sex change” as a solution to their distress.
Puberty blockers not only block puberty but also block the resolution of gender dysphoria. This is why they inevitably lead to hormones and surgeries, and afterward the percentage of those who die by suicide increases, and the more years that pass after medicalization, the higher the rate of patients who detransition.
Thanks for that useful analysis. It certainly makes sense that the decline in desistance after 2000 could be explained by the advent of puberty blocker treatment in the 90s
This is a great article. I'll just highlight a few ideas and add a few nuances.
• The influence of trust in the doctor-patient relationship is central to the whole issue of the medicalization of gender dysphoria. From isolated cases in the past to the current epidemic, the ultimate explanation for this whole scandal lies in the erroneous and messianic belief that it is possible to change sex, a belief set in motion and sustained by excessively arrogant and conceited researchers who have sold people struggling—for various reasons—with their gender a magic bullet as ineffective as it is poisonous.
• When we talk about low-quality studies with small sample sizes, poor design, and risk of bias, we're referring to studies like the one that proponents of the medicalization of gender dysphoria tried to hide and whose results they lied about, as I explain and show here:
https://cabrerae.substack.com/p/puberty-blockers-do-not-improve-the
• When analyzing the effects of puberty blocking, it's crucial to understand that its irreversibility guarantees the use of cross-sex hormones and, in many cases, mutilating surgeries. The risks include: infertility, lack of sexual function (anorgasmia), pelvic floor dysfunction, increased risk of breast cancer, weight gain, symptoms of premature menopause, cardiovascular complications, type 2 diabetes, and a possible reduction in life expectancy.
In summary: the promotion and use of puberty blockers in cases of gender dysphoria is absolutely contrary to medical ethics.
Thank you, Isobel, for this excellent critique of the limits of capacity for children to give any sort of consent at all, let alone informed consent to procedures and treatments that will cause iatrogenic harms to both their bodies and their minds.
I really appreciated this sentence because it is a good example of how the system operates in real life: "For instance, I have observed instances of patients with full blown dementia signing surgical consent forms for hip-fracture surgery." A few years ago, a close relative had a severe mental health crisis which necessitated his admittance to an inpatient mental health facility. He was admitted under an informed consent protocol, which I later challenged after he was safely admitted, and I was told that "this makes it easier for us because otherwise we have to get the police involved and do a lot more paperwork"!
And "There is a difference between asking someone, “Do you understand?” and receiving a “Yes” response and asking someone to explain, in their own words, what you have just told them." In my professional work as a midwife, I was very aware of the difference between women agreeing to something and women understanding what they were agreeing to. For example, unless there is a discussion first, women do not realise that agreeing to an induction of labour includes having a cannula inserted, having continuous CTG monitoring and giving up their hopes of having a water birth.
It is not possible to have an informed consent decision about issues that children lack the capacity to contemplate or understand. How do you talk about losing the prospect of never having a pleasurable sex life or an orgasm with a 14-year-old who never even started puberty?
Personally, the most frightening aspect of "gender affirming care" for children/teens is missing out on that crucial brain maturation that is vital for the development of our frontal lobe/executive functioning that distinguishes adults from children. https://lucyleader.substack.com/p/time-critical-brain-development
Thanks Robin. It looks like you and I are pretty much on the same page when it comes to the safeguarding capacities of so-called “informed consent” - pretty much non-existent I’d say! Patients have, at least up until now, had a lot of trust in the caring professions. They assume we’re all guided by beneficence and non-maleficence and proper scientific enquiry. It worries me that activist clinicians are abusing that trust by prioritising ideology over patient safety. This can only have a detrimental effect on trust in medicine as a whole and this will be bad for everyone, not just gender clinicians and paediatric endocrinologists.