Puberty blockers: Can a drug trial solve one of medicine's most controversial debates?

[IwantToRetire]

It is among the most delicate and controversial challenges in modern medicine - how to determine whether the benefits of puberty blockers (or drugs that delay puberty) outweigh the potential harms.

This question came to the fore in June 2023 when NHS England proposed that in the future, these drugs would only be prescribed to children questioning their gender as part of clinical research.
Since then, a new government has arrived in Westminster and Health Secretary Wes Streeting has said he is committed to "setting up a clinical trial" to establish the evidence on puberty blockers. The National Institute for Health and Care Research is expected to confirm soon that funding is in place for a trial.

The dilemma that remains is, how will such a trial work?

Eighteen months since the announcement there is still a lack of consensus around how the trial should be conducted. It will also need to be approved by a committee of experts who have to decide, among other things, whether what's being tested might cause undue physical or psychological harm.

But there is a second unanswered question that some, but by no means all, scientists have that is more pressing than the first: is it right to perform this particular trial on children and young people at all?

Article by Deborah Cohen continues at https://www.bbc.co.uk/news/articles/clyd2qe5kkjo

So children will be harmed in the name of research, rather than access adult data. For God’s sake Wes Streeting, sort this out!

Thank you @BonfireLady for great points. I read the InDepth article this morning and was (a bit) heartened by the factual narrative of the article (and that it was actually published by BBC). Very well written. Again, feel this article being allowed is yet another teeny, tiny step back from the previous stance of pretending there was nothing to see except bigots and shrill women.

Still felt there was a tiny amount of deference to the idea that "trans" is a tangible, biological medical issue instead of a mental health problem, and no explanation as to how or why treatment pathways had suddenly shifted from psychological care to drug treatment. If I were someone reading this article with no knowledge of all the furore I would wonder what had prompted this fundamental change.

Still felt there was a tiny amount of deference to the idea that "trans" is a tangible, biological medical issue instead of a mental health problem, and no explanation as to how or why treatment pathways had suddenly shifted from psychological care to drug treatment. If I were someone reading this article with no knowledge of all the furore I would wonder what had prompted this fundamental change.

This is consistent with the Cass Report, which sees gender identity as a fact rather than belief i.e. that it's true that we all have one. However, it cautions against seeing it as the first answer to a child's distress.

As I don't believe we all have a gender identity myself, this doesn't sit right with me at all. It's equivalent to NHS led exorcisms to remove evil entities that are "causing" distress with a side helping of permanent body modification (both within the endocrine system and with body parts, once the child is old enough for surgery and believes that this next step in the affirmation journey is what they need).

However, the Cass recommended approach does mean that the vast, vast majority of children would not end up on a medical pathway at such a young age and there's a good chance that a truly neutral therapeutic approach will resolve their dysphoria.

What's more no child would go on this pathway at all until the puberty blocker trial is complete. Which itself need to meet ethics approval.

So it's all still pointing at the same place, just without denying the existence of gender identity as a "thing".

if the aim of treatment isn’t really the treatment (how the patient sees their own body) but how other people respond to it, then this ‘treatment’ is as much social as medical. This is more problematic, because nobody can guarantee the patients the sort of social reception they will get

This is what 'passing' is all about. It's not about the person having the treatment seeing their body differently, it's about attempting to convince others that they are the opposite sex.

I think the first question which needs to be answered regarding this 'treatment' is what, exactly, is it supposed to achieve?

Is it supposed to help the patient to accept their body? If so, why are physical treatments being used instead of helping the patient to accept their body as it is?

If it's really to try to dupe other people into believing that that person is the opposite sex, how can this be in any way ethical?

I assumed that this new "In Depth" series is some compensation for what have been quite serious cuts to in depth reporting.

ie newsnight is now a chat show, so some of the significant investigations they had now wont happen.

What is worrying is whether Deborah Cohen would have been able to get the BBC to publish this if she hadn't previously been an employee.

So really good that this did publish it, but doubt it shows a committment to any ongoing analysis of what happens after Cass.

But also easy for them to hide away in this new part of their web site.

ie it wont be on tv, so wont be seen or read by many.

But in terms of the actual article, I have always wondered how you can use young people as guinea pigs. It's not like adults signing up to a drug trial is it.

Added to which taking part in the drug trial may impact negatively for the child's future.

The aim of the treatment is to address gender incongruence.

Gender incongruence harms people in multiple ways.

Some of these harms emerge 'internally' - body dysphoria, the subjective personal experience of feeling at odds with a body that is developing/has developed a particular way. The treatment can address this by slowing or stopping these changes - some of which are irreversible - from progressing further. Successful treatment allows a person to effectively 'jump the rails' and progress along a developmental path that no longer causes this incongruence.

Some of these harms have 'external' sources - the distress that comes from being subject to social dynamics that deny a person's own sense of self.

We are acutely aware of when people are grudgingly humouring us. Those microaggressions are very obvious - we are supposed to know - that's the point after all.

We are subject to increased hostility if identified as trans people; this hostility alone causes distress. It is distressing to be misgendered, especially when it is clear that this is being done deliberately to punish us for transgressing against social expectations applied to everyone based on the sex they were assigned at birth.

You could put one of us in a rocket and fire us off into space, never to be perceived by another human being again. It would not stop us from experiencing sex dysphoria.

For as long as you believe that "misgendering" is motivated by nastiness, you will struggle with it for that reason. It might be worth considering that most of the time, people use pronouns automatically, subconsciously, to refer to you. Those pronouns may be based solely on habit, or on perception of you as a man, with no intention to mock or to be cruel. But if you think the worst of someone, you will always believe they have it in for you.

It is not transphobic to instinctively recognise someone's sex, and it is not transphobic to refer to someone with pronouns based on that sex. Many people, me included, do not much care what "gender" someone sees themselves as being or what image someone tries to present to the world. They may find some presentations distasteful - I don't tend to like the results of cosmetic surgery, or for that matter heavy makeup. Again, failing to keep that distaste completely hidden may be a little rude, but it is not healthy to frame it as hostility.

No-one has any obligation to see you as you see yourself, or as you would like to see yourself.

Excellent article by Victoria Smith in Unherd

https://unherd.com/newsroom/nhs-puberty-blocker-trials-are-unethical/

the comments are worth a read too.

How do you sort the wheat from the chaff? The true-trans from the sprogs who will grow out of it? Even the ones who have all the blockers and all the hormones and all the surgeries who never voiced regret, how do you rewind time and do it over to discover that their lives would have worked out fine anyway, with none of it?

Very good piece, as usual, from VS. I can't agree with the 'ultras' who criticise Cass for basically not saying, it's all a load of bollocks. That would have probably left the Review dead in the water. Just seemed pragmatism to me.

this is being done deliberately to punish us for transgressing against social expectations applied to everyone based on the sex they were assigned at birth.

I would think it more likely that those who are rude about a trans identity are doing so not because such an identity 'transgresses' social expectations applied to everyone based on sex but because trans identities enforce and rely on those expectations.
There are plenty of women who are sick to death of the idiotic presentational and behavioural norms that have confined them forever, and who are glad to see male people adopting them, because the adoption of these norms by people of both sexes helps to sever the association between being a woman and appearing a certain way.

It is, then, insulting when some of the male people who present in this way assert that it is because they are women.

It is also pretty offensive to equate "grudgingly humouring" with a microagression. Asking someone to deny the evidence of their senses is asking A LOT. If people go as far as grudgingly humouring the request, they have already gone further than it is reasonable to expect. Is it a microaggression to be a bad actor - or is the real microagression the requirement placed on other people to join in a pretence that is deeply offensive to them?

You think you are being punished for transgressing against social expectations applied to everyone based on the sex they were assigned at birth.

Have you any idea what it's like to be a woman who doesn't comply with those sort of expectations? Of course you don't.

What is 'gender incongruence'?

Is it something to do with a dislike of your body? You imply this with this statement: body dysphoria, the subjective personal experience of feeling at odds with a body that is developing/has developed a particular way

But then you talk about 'external' sources - the distress that comes from being subject to social dynamics that deny a person's own sense of self.
Do you expect everyone else to see you as you want to be seen? Because this is completely unreasonable. None of us has the power or the right to be seen as we want to be seen by everyone else.

But what has this got to do with body dysmorphia anyway?

Is your 'gender incongruence' a wish to have a different body? Or is it about wanting to behave in a non-gender-stereotypical way. Because many of us do that without changing our bodies.

That's a supermarket assistant. It's a bit low to stick their photo on here and laugh at it. People should be free to dress how they like and call themselves what they like. Let's stick to protecting our children, and ourselves, and our spaces.

It's a photo of a bloke in fetish gear with a whip.

Nobody's laughing.

I didn't spot the whip 🫣

Ruby…. “now presents as a woman full-time.”

I don’t know any woman who presents in that way, leather cat-o-nine-tails whip in hand or not.

Bit cruel of John Lewis to expose Ruby like that imo.

Agreed with pretty much all of this, for ref.

You can't force people to perceive others in a particular way; you can only help them understand the impact of their actions and beg them to act with compassion. Most people manage to do this in good faith.

This is so well put.

All the more so because of your personal journey on all of this (that you've shared on other threads) 💐💪

Allow me to rephrase:

-A. Feeling that your body is wrong (incongruence) can make you sad (dysphoria). This is an internal source of dysphoria. If you were the only human on earth you would still feel this.

-B. Feeling that your body is wrong AND that people are defining your existence using a surface-level impression of the parts that are making you sad can also make you (even more) sad. This is an external source of dysphoria. If you were the only human on earth you would not feel this.

-C. Feeling that your body is wrong AND that people are actively abusing you over feeling sad about your body being wrong can also make you (even more) sad. This is an external source of dysphoria. If you were the only human on earth you would not feel this.

-D. Feeling that your body is wrong AND knowing that treatment exists which can ease the feeling of incongruence (A) but you are being deliberately denied it by policy because some people don't believe you are really experiencing (A), or that (B/C) is the correct way for you to be treated, can also make you (even more) sad. This is an external source of dysphoria but it feeds back into the internal root source.

Lots of stuff makes me sad. I deal with it. Hanging my hopes of happiness on strangers means I would never be happy.

Thanks. In that case, may I ask you to consider these questions? I'm not particularly looking for an answer, so please don't feel obliged to reply.

Is my son still my son if he would like me to refer to him as "she"? If he is not my son, how should I process my loss? And if he is my son, how do I reconcile that with pretending he is a woman? If he is a woman, that makes him my daughter, does it not? But I know that, in fact, he is my son. You see, that act of "begging me to act with compassion" is an act of asking me to deny my son's existence. Unless you are astonishingly empathetic, you can have no idea of the turmoil, dissonance and distress that causes a parent. And that is without even going near the worry that my son will ruin his health in pursuit of an impossibility.

See points A and D above.

Exactly this. And the idea that it's necessary to change your body to look like someone you're not (in order to be your "true self"), and then expect everyone to go along with the pretence that you've changed sex in order to be happy is just ludicrous.

Be yourself in the body you have. It's so much easier - and more honest.

Agreed with pretty much all of this, for ref.

👍

You can't force people to perceive others in a particular way;

👍

you can only help them understand the impact of their actions and beg them to act with compassion. Most people manage to do this in good faith.

Yes (although hopefully no begging is required) most people do act in good faith.

The difficult bit is where some people are trying to force people to perceive others in a particular way e.g. where TW are forcing women to accept them in women's sports.

All the compassionate begging in the world doesn't change the fact that this is wrong. Whilst I'm empathetic to someone who genuinely believes that they have a gender identity and that it's different from their sex, even though I don't believe in gender identity myself, I'm not going to accept their belief as justification for this. It's not good faith to force me to do so. So hopefully "most people" would see that good faith starts and ends with recognising that some people have gender dysphoria, but this doesn't mean that their strong feelings of being the opposite sex need to be accepted as fact by everyone else.

It's a hard no. Nobody should be able to self identify into the sports, spaces and services of the opposite sex. Sex (our physical bodies) is fact. Gender identity (a feeling that some people have) is belief. I don't accept anyone imposing their belief in gender identity on others, any more than I would another belief.