On The Myth That Puberty Blockers Are "Reversible"

reversible

/rɪˈvəːsɪb(ə)l/

adjective

1. able to be turned the other way round.

   "a reversible pushchair seat"

2. (of the effects of a process or condition) capable of being reversed so that the previous state or situation is restored.

   "potentially reversible forms of renal failure"

pause

/pɔːz/

verb

1. interrupt action or speech briefly.

   "she paused, at a loss for words"

noun

1. a temporary stop in action or speech.

   "she dropped me outside during a brief pause in the rain"

disingenuous

/ˌdɪsɪnˈdʒɛnjʊəs/

adjective

1. not candid or sincere, typically by pretending that one knows less about something than one really does.

   "he was being somewhat disingenuous as well as cynical"

One of the most crucial parts of my last post was the importance of understanding the way puberty blockers are actually used. The realities of this are vital to really understanding the pathway.

There is a great deal of misinformation about their use, and most of it is perpetuated by those that use them. The word “reversible” is used regularly. Puberty blockers have been used for decades to treat central precocious puberty (CPP), a condition where puberty starts much earlier than acceptable (before 8 for girls, before 9 for boys). Endocrinologists often say “we’ve used puberty blockers for decades, why all the fuss?”when they disingenuously mean for CPP, not for gender non-conforming children. For CPP, puberty blockers “block” this process, allow the child to grow chronologically older, before the injections are ceased, their blocking effects are “reversed”, and puberty continues at a more suitable age.

But this is not what happens in the treatment of gender non-conforming children. The crucial clarification of this came in the case of Bell/Mrs. A vs Tavistock. The relevant section starts at paragraph 48. There is a good discussion around the development of the use of puberty blockers, then discussion around the purported reason for their use. Is it to give children time to think, to prevent suicide, or to help children “pass” better in later life?

There then follows the crucial paragraph (my bold):

57. No precise numbers are available from GIDS (as to the percentage of patients who proceed from PBs to CSH). There was some evidence based on a random sample of those who in 2019-2020 had been discharged or had what is described as a closing summary from GIDS. However the court did have the evidence of Dr de Vries. Dr de Vries is a founding board member of EPATH (European Professional Association for Transgender Health) and a member of the WPATH (World Professional Association for Transgender Health) Committee on Children and Adolescents and its Chair between 2010 and 2016, and leads the Centre of Expertise on Gender Dysphoria at the Amsterdam University Medical Centre in the Netherlands (CEGD). This is the institution which has led the way in the use of PBs for young people in the Netherlands; and is the sole source of published peer reviewed data (in respect of the treatment we are considering) produced to the court. She says that of the adolescents who started puberty suppression, only 1.9 per cent stopped the treatment and did not proceed to CSH.

Dr Annelou de Vries is one of the leading Dutch researchers into this protocol. Her work and that of her colleagues is frequently cited by gender clinics as the justification for their practice (and often misrepresented, particularly around regret, which I will address in the near future). Here, she clearly states that puberty blockers are not a pause, they are not reversed, and for the vast majority of children they are the first step on a progressive pathway.

There were two important consequences of this. The first is that the Tavistock could not produce any data to say either way whether this was true for their clinic or not. If you read on after paragraph 57, they had no real idea, but concurred overall (59). A lack of data in gender clinics is a concern.

The second consequence is that the judges considered this an important part of their ruling, particularly around consent. If children starting puberty blockers progress, at a rate of more than 98%, to cross sex hormones, then the consent process at the start of puberty blockers has to consider this. Can a child fully understand these implications? Consider these two paragraphs (again, my bold):

137.The defendant argues that PBs give the child “time to think”, that is, to decide whether or not to proceed to cross-sex hormones or to revert to development in the natal sex. But the use of puberty blockers is not itself a neutral process by which time stands still for the child on PBs, whether physically or psychologically. PBs prevent the child going through puberty in the normal biological process. As a minimum it seems to us that this means that the child is not undergoing the physical and consequential psychological changes which would contribute to the understanding of a person’s identity. There is an argument that for some children at least, this may confirm the child’s chosen gender identity at the time they begin the use of puberty blockers and to that extent, confirm their GD and increase the likelihood of some children moving on to cross-sex hormones. Indeed, the statistical correlation between the use of puberty blockers and cross-sex hormones supports the case that it is appropriate to view PBs as a stepping stone to cross-sex hormones.

138. It follows that to achieve Gillick competence the child or young person would have to understand not simply the implications of taking PBs but those of progressing to cross- sex hormones. The relevant information therefore that a child would have to understand, retain and weigh up in order to have the requisite competence in relation to PBs, would be as follows: (i) the immediate consequences of the treatment in physical and psychological terms; (ii) the fact that the vast majority of patients taking PBs go on to CSH and therefore that s/he is on a pathway to much greater medical interventions; (iii) the relationship between taking CSH and subsequent surgery, with the implications of such surgery; (iv) the fact that CSH may well lead to a loss of fertility; (v) the impact of CSH on sexual function; (vi) the impact that taking this step on this treatment pathway may have on future and life-long relationships; (vii) the unknown physical consequences of taking PBs; and (viii) the fact that the evidence base for this treatment is as yet highly uncertain.

In the setting of treating children with gender incongruence, puberty blockers are almost never reversed. The consequences are lifelong. The evidence base for this treatment is as yet highly uncertain. The Tavistock, a major worldwide centre of the treatment of children could not present any good evidence base to the judges.

Why then, do gender clinics consistently claim that puberty blockers are reversible? Many members of the public believe that this “pause” gives children time to think about their identity. It is, the public thinks, during this time they decide whether or not they will progress with the treatment pathway onto cross sex hormones. Many members of the public think children might decide not to proceed. But we know hardly any do. So why do the gender clinics insist on misleading the public that this is a common outcome?

In Australia, we do not know the numbers of children who start puberty blockers, and how many of those progress onto cross sex hormones. I asked my local gender clinic and they wouldn’t tell me. No local clinic has published data on its patients, nor any long term follow up, I suspect because they have no idea themselves. But the 98% figure certainly reflects the experience from other clinics worldwide. Dr Norman Spack, the doctor responsible for introducing the Dutch Protocol to the USA (who, after seeing it presented at a meeting, was left “salivating”) proudly stated in an interview in 2016 that 100% of his 200 patients he had placed on puberty blockers at that time had progressed to cross sex hormones.

On top of this in Australia, doctors and advocates also state that the fact that most children progress is a clear sign that doctors in gender clinics are selecting the right children. Dr Fiona Bisshop, president of AusPATH, claimed this in an article in the Sydney Morning Herald in December 2020.

Which is it? Either puberty blockers are “reversible” and give children “time to think” or puberty blockers are the right first step along the pathway for the children they have definitely selected to be the right candidates to be transgender adults. It can’t be both, the statements are antithetical to each other. The only way that they can be reconciled is if the only thing children are actually thinking about is what an amazing decision they’ve made, not whether it’s the right decision, or whether there is an alternative.

There is significant concern about the process of thinking that goes on after the commencement of puberty blockers. These children exist in a purely affirmative environment. What if they have doubts? What option do they have to explore other avenues? What if parents have doubts? Does the process itself generate persistence, rather than “create space to decide”, a concern raised by the UK’s Health Research Authority mentioned in the judicial review?

The answer is not clear. It’s another burning question that people outside of gender clinics want to discuss, but those inside gender clinics think is solved - they are just selecting the right children, so doubt doesn’t come into it.

It is remarkable to me how they can be so confident. They are not saying they are accurately diagnosing gender dysphoria with 98% accuracy. They are saying they can be sure of a child’s future gender identity with 98% accuracy. No one would pigeon hole a child’s sexual orientation in early adolescence, but gender identity? At 10 or 11 years of age? Sure! Why not?

Once again, we have a situation where the gender clinics know something, but say nothing. Just like they know that this pathway can lead to infertility and sexual dysfunction, they also know that they rarely reverse puberty blockers and claim these children don’t actually need any time to think because the child knows they are trans, even as young as 10, and everyone has decided the best thing to do is fully transition. But they say nothing. Why?

So I have a request of my gender clinic colleagues: if you are so sure that you are selecting the correct children right from the start, and that there is no need to reverse the action of puberty blockers, when you see someone say that “puberty blockers are reversible”, correct them! Don’t allow this misinformation to continue.

When a random member of the public tweets “puberty blockers are reversible” be proud of your clinical acumen and correct them to avoid misinformation about the treatment of children. You can tweet in reply:

We rarely stop puberty blockers because we are sure that we have successfully identified children, some as young as 10, who will have trans identities as adults and therefore we are confident that they will require treatment with cross sex hormones to help them pass as adults.

(That is fewer than 280 characters, so feel free to copy and paste it.)

When a media article appears that is supportive of the affirmative pathway, for example in the ABC, or Guardian Australia, don’t allow them to perpetuate the myth that puberty blockers are reversible, instead be proud of the fact you are accurately selecting the right children and advertise that fact. Make sure the media report accurately on this pathway. Let’s dispel this myth once and for all, together. Don’t leave it up to me and others with concerns to do it alone.

Stop being so disingenuous. You know you progress children at high rates. You know the implications of this. You must be convinced it is the right thing to do, so why aren’t you proudly stating it? Let’s have some honesty.

“We don’t reverse puberty blockers because we are sure we are right about the children we select. All of these children are going to be trans adults. Yes, even the 10 year olds.”

“We know this pathway can lead to sterility and sexual dysfunction, but we are sure we are right because [insert justification here].”

Say it loud and proud. Why the fear of being honest?

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Post script: thank you for all your supportive comments and emails. I read them all, including the heartbreaking personal and professional stories. They have all helped me continue my push for honesty and open disclosure from clinics in Australia. I intend to reply to emails when I can, in time, in between all the RSV and Influenza. Please let me know also if there is a specific topic or question anyone would like me to cover.