Major Uncertainties in the Use of Puberty Blockers -- Canadian Research

"[Doctors should] clearly communicate [the major uncertainties that remain with children and parents and check] whose values they are prioritizing [when prescribing puberty blockers and masculinizing or feminizing hormones to youth]."

"We are very uncertain about the causal effect of the [drugs] on depression. Most studies provided very low certainty of evidence about the outcomes of interest, thus we cannot exclude the possibility of benefit or harm."

"Since the current best evidence, including our systematic review and meta-analysis, is predominantly very low quality, clinicians must clearly communicate this evidence to patients and caregivers."

"[Guideline developers and policymakers should also be transparent] about which and whose values they are prioritizing when making recommendations and policy decisions."

Report: Canadian research

 

According to a team of researchers in Canada, an absence of evidence on the efficacious use of puberty blockers and cross-sex hormones that have been increasingly seeing use on children presenting with gender dysphoria along with teens self-identifying as transgender amounts to medical dysfunction, potentially harming the futures of many of these children. Whether, for the time being, their use is helpful or harmful, cannot be discerned given the low certainty surrounding the issue and absence of research. 

When in doubt -- abstain, or make it quite clear that the prevalent use of cross-sex hormones and puberty blockers on the very young is fraught with uncertainty regarding future impact. A major British review that had been commissioned by the National Health Services of England found evidence questioning the safety and efficacy of puberty blockers for children with gender dysphoria to be weak, "built on shaky foundations".

As a result of the Cass Review's conclusion of doubt, doctors in the United Kingdom were instructed to stop routinely prescribing puberty blockers temporarily, to children and  youth under 18 years of age. More latterly, after independent expert advice concluded such drugs pose an "unacceptable safety risk" the ban became indefinite.

In Canada, however, no impact from the Cass Review has been seen in its gender-affirming approach, with the Canadian Paedriatric Society expressing criticism of what it terms "significant limitations, biases and inaccuracies" in the review, the result of a four-year enquiry. The CPS writing in its journal "The model of gender-affirming care in Canada differs in many ways from the approach that had been in place in the U.K".

According to a federally funded study, however, 174 children under 16 referred to one of ten gender-identity clinics in Canada saw 74 percent placed on puberty blockers, with close to two-thirds progressing to masculinizing or feminizing hormones.

"There's not enough reliable information."

"We really don't have enough evidence to say that these procedures are beneficial."

"Few studies have looked at physical harm, so we have really no evidence of harm as well."

"There's not a lot that we can say with certainty, based on the evidence."

Chan Kulatunga-Moruzi, an author of the review

Those who begin puberty blockers for the most part tend to progress to gender-affirming hormones which induce sex characteristics such as facial hair or breast enlargement. Giving children identifying as transgender time to decide whether to proceed to transition, while relaxing their feelings of distress over body changes that disturb them. Concerns relate to whether the drugs are locking in a gender identity --their transition becoming an inevitable expectation.

Although the process was initially thought to be fully reversible,  the potential seems to augur for long-term and irreversible effects -- according to the Canadian research team -- in their finding published in the journal Archives of Disease in Childhood. Screening 6,736 research titles involving puberty blockers, the study found low certainty of evidence on the effects of puberty blockers on depression, an oft-cited argument for their use on distressed youth.

"Since the current best evidence, including our systematic review and meta-analysis, is predominantly very low quality, clinicians must clearly communicate this evidence to patients and caregivers," researchers wrote. Photo by Getty Images

Gender Dysphoria : Transgender Boom

"I do have the same concerns the Tavistock clinic faced. I think it just  moves us to, let's slow down and make sense of what is going on."

"All of these decisions ... concerning social, medical or surgical transitions, these are big decisions and they deserve the time, they deserve the respect that's needed."

"The changes that have occurred in Sweden, Finland and now the U.K. should give us food for thought . Let's evaluate what is going on here."

"I think frequently professionals, doctors feel pushed to make these decisions around medications sooner than probably what we would feel comfortable with. That really results in a type of care that is not thoughtful and that could lead to negative outcomes."

"With this cultural shift in the way we are looking at gender, there are definitely youth who are transgender who feel more comfortable and safe to come out. And that's wonderful."

"We also have to acknowledge that at the same time ... there are also probably going to be some who are identifying as transgender who maybe are not."

Dr.Joey Bonifacio, pediatrician, gender identity, St.Michael's Hospital, Toronto

"No one makes these decisions lightly."

"They are made very slowly very cautiously, after long discussions with these youth and their parents."

Dr.Margaret Lawson, medical director, gender diversity clinic, Children's Hospital of Eastern Ontario

The Tavistock clinic in London was the only specialized centre for gender care in Britain until it was shut down amid controversy. Photo by Peter Nicholls/Reuters

There has been a surprising and undeniable spurt of young people presenting with gendr dysphoria. And as their numbers soar the health care system should be careful to spend some time examining just why these trends are occurring; at the same time as they assume a thoughtful, 'neutral' approach to each young patient, urges Dr. Bonifacio. Who could argue with that common-sense recommendation in the face of overwhelming numbers of children suddenly coming forward as rejecting their birth-designated gender?

Britain's recent decision to close down its Tavistock clinic for gender issues to replace it with a network of smaller centres, made headlines in gender health care groups. According to an independent review the clinic was seen to be giving short shrift to patients' non-gender mental health problems when it was unclear regarding the long-term effects of puberty-blocker drugs often representing the first step in gender transition.

Patients await long lists of others before them seeking medical attention, Dr. Bonifaio acknowledged -- but doctors and other professionals still must see their way clear to thoroughly addressing mental health issues if any, that children experience as well as gender dysphoria -- the belief one does not belong to birth-assigned sex -- before gender transition begins with hormone treatment and eventually, surgery.

Dr. Bonifacio has subspecialty training in adolescent and social pediatrics behind him as a former medical director of the SickKids Hospital gender clinic in Toronto. His recommendations ring in as a rare case of an expert at the heart of transgender health care in Canada questioning some of its practices. The rapid increase in patients presenting as transgender in the last few years, dominated by girls just entering adolescence, underscores the ongoing debate on the topic.

Gender dysphoria in the past was likelier to appear in younger boys, but the Trans Youth Can! research project shows that patient volumes at ten participating clinics swelled from virtually none in 2004, to over 1,000 in 2016. Of that number, some 80 percent were born female. Children on the autism spectrum and other neurodivergent patients also show up, accounting for roughly a third of patients at the Tavistock clinic, according to the U.K. review.

According to epidemiologist Greta Bauer, co-director of Trans Youth Can!, the explosion in patient demand reflects the growing acceptance of transgenderism following years of stigma and hatred -- underestimating the number of youth "who know they're trans and need gender affirming care". Clinics believe that puberty-blocking drugs safely provide a reversible 'pause' in hormonal development while young people negotiate their options.

Last year Swedish authorities decided to ban the use of puberty blockers and cross-sex hormones for most minors, under the argument that insufficient evidence existed to support the treatment. Similar steps were taken by Finland which felt that psychotherapy should be pursued as an investigative tool to determine the authenticity of transgender claims before drugs are prescribed for children.

In Canada, the Gender Pathways Service at London Health Sciences Centre in Ontario states that family physicians referring patients should consider beginning the patients on puberty blockers prior to first appointments at the clinic. A form letter sent out to physicians notes wait times are long and the drugs may decrease distress while awaiting appointments.

Some health care providers, points out Dr. Bonifacio, misinterpret what 'affirmative' care is meant to represent as the predominant approach. "They think affirmative care is you follow whatever pronouns (patients) care to use and start medication as soon as possible." He cited a commentary published by a major Canadian journal that the term means to holistically support the patient in their identities and needs and "refrain from directing a child toward any particular identity".

Parents sometimes speak of multiple pupils in their children's classes at school suddenly presenting with gender identity issues. Leading many gender-treatment professionals to reject the notion that the growing cohort of adolescent girls identifying as transgender may be the result of influence through "social contagion". 

Symptoms

Gender dysphoria might cause adolescents and adults to experience a marked difference between inner gender identity and assigned gender that lasts for at least six months. The difference is shown by at least two of the following:

• A difference between gender identity and genitals or secondary sex characteristics, such as breast size, voice and facial hair. In young adolescents, a difference between gender identity and anticipated secondary sex characteristics.
• A strong desire to be rid of these genitals or secondary sex characteristics, or a desire to prevent the development of secondary sex characteristics.
• A strong desire to have the genitals and secondary sex characteristics of another gender.
• A strong desire to be or to be treated as another gender.
• A strong belief of having the typical feelings and reactions of another gender.

Gender dysphoria may also cause significant distress that affects how you function in social situations, at work or school, and in other areas of life.

Mayo Clinic