Debate on the puberty blocker trial this afternoon, 23rd June

[RoseInAPot]

Opposition day debates today, instigated by the LOTO Kemi Badenoch. She has chosen two issues: defence, and the puberty blocker trial.

Sometime this afternoon, will be worth a watch.

Most drugs are harmful! It's why you can't get most of them without a prescription, and why even over-the-counter ones come with sales restrictions, strict dosage instructions and long listsxof potential side effects.

The question isn't "is it harmful?" but "does the risk of harm outweigh the benefits?" In the case of precocious puberty, it's been determined it doesn't. (It's better for the patient to take the risk associated with the drug than allow the problems associated with not taking it.) In the case of gender dysphoric children, there are strong reasons to believe it does.

This argument does not work.

”Cass said we don’t know if there are harms.”

That is being used backwards.
Cass did not say puberty blockers are safe. She said the evidence is weak and uncertain. In children’s medicine, uncertainty is not a green light. It is a reason for caution.

NHS England concluded there is not enough evidence to support the safety or clinical effectiveness of puberty blockers for children with gender incongruence/gender dysphoria. That is why they are not routinely available.

”There is no evidence of long-term harm.”

There is evidence of harm and evidence of serious risk.

NHS England states GnRHa may reduce the expected increase in lumbar or femoral bone density during puberty. That matters because puberty is when children build adult bone strength.

The Commission on Human Medicines advised there is currently an unacceptable safety risk in continued prescribing to children outside proper safeguards.

The FDA has also added warnings for GnRH agonists in children, including pseudotumor cerebri, also called idiopathic intracranial hypertension. Lupron Depot-Ped’s label also refers to psychiatric events, convulsions and other serious adverse reactions.

So no, these are not harmless pause buttons.

”If they were harmful, we’d see it in children treated for other conditions.”

We do see safety concerns in other uses. That is why paediatric GnRH agonist labels contain warnings.

But more importantly, this is a false comparison.
Central precocious puberty is a real, objective endocrine disorder: puberty starting abnormally early. The aim is to move development back towards normal timing.

Gender distress is completely different. In these children, puberty is not medically abnormal. The drug is being used to stop normal development because the child is distressed by it.

Different condition. Different purpose. Different ethics. Different risk-benefit calculation.

”The risks and benefits are unclear.”

Exactly. That is the problem.

You do not give powerful puberty-suppressing drugs to children on the basis that the risks and benefits are unclear. Especially not when the child is 11, distressed and cannot possibly understand future fertility, sexual development, bone health, brain development or lifelong medicalisation.

”But the trial will measure benefits.”

Measuring things is not the same as having a coherent positive outcome.

What is success?

If the child still has gender dysphoria, that is not success.

If the child goes from blockers to cross-sex hormones, that is not “time to think”. It is a pathway.
If the child feels temporarily better because normal puberty has been stopped, that proves nothing. An anorexic child may feel better if you help her avoid weight gain. That does not make it good medicine.

Puberty blockers do not and cannot solve gender dysphoria.

They cannot make a girl into a boy or a boy into a girl. They cannot make the body match the belief. They cannot resolve the underlying distress. They can only suppress healthy puberty.

The best outcome is that the child no longer has gender dysphoria and can live peacefully in their own body. Puberty blockers cannot produce that outcome.

So the real question is still unanswered: what good are these drugs supposed to do that careful, whole-child psychological support cannot do more safely?
Because if the answer is “stop puberty”, that is not treatment. That is the harm.

Hi Audresy. I have pm'd you. Please check.

How did I know Dr SingleSexSpacesInSchools would be along to share his uneducated opinion.

The best outcome is that the child no longer has gender dysphoria and can live peacefully in their own body. Puberty blockers cannot produce that outcome.

No, and they're not intended to, they're intended for short term use while the patient, family and clinical team decide the next best cause of action (you know, the people who are normally involved in making clinical decisions, not politicians, not random male mumsnetters with no expertise and axes to grind). What has also never been shown to be effective in curing gender dysphoria is talk therapy, there is not a single shred of evidence in fact that psychological interventions cure people of being trans, and Cass also admitted this. The only thing which has ever with sound reliable repeatable scientific evidence been shown to relieve gender dysphoria is allowing people to transition.

What do you mean by "transition" - it implies that there is a process with an identifiable end point. There isn't. Humans can't change sex. Saying an unspecified process is a cure is naive at best.

What has been shown to help gender confused children is puberty. Why stop the thing that is likely to make the majority feel better?
If it makes you feel better, call puberty transitioning to adulthood.

What does ‘transition’ mean in reality?

Noting that adult women are limited to 6 months on these drugs due to osteoporosis risk, I looked up dosages a couple of years ago & the puberty blocking dose for children was significantly higher than for women with PMDD. It was something like 2-3x higher. In kids. At a key point in their development, when they are laying down bone density to carry them through adulthood. Make it make sense, please.

I’ll note first that you failed to address most of the points raised previously, and the few you did respond to came without any supporting data or evidence beyond your own assertions.

Your argument still collapses at the same point: what is the actual good outcome?

You now say blockers are not meant to resolve dysphoria, just to create time while the child, parents and clinicians decide what to do next.
But that is precisely the problem. A drug that stops normal puberty is not a neutral waiting room. Puberty is development. Bone development, brain development, sexual development, fertility and adult function are all bound up in it. Evidence shows measurable impacts: for example, studies have found reduced bone mineral density in adolescents on GnRH analogues, raising concerns about long-term skeletal health:
https://pubmed.ncbi.nlm.nih.gov/28119276/

It is also misleading to describe this as a simple “pause,” as if puberty can later resume in the same way. Biological development is time-sensitive, and interrupting it alters trajectories in ways that are not fully reversible or predictable. There are ongoing concerns in the literature about potential long-term effects on sexual function, fertility, and overall health, and the extent to which these outcomes can be fully restored remains uncertain. That uncertainty alone undermines the idea that this is a neutral or consequence-free intervention.

If the treatment is only “time to think”, then why has the evidence not shown that it actually works as time to think? Why do so many children who start blockers proceed to cross-sex hormones? Data from the Dutch cohort often cited in support of this pathway shows that the vast majority, over 95%, of those placed on blockers went on to cross-sex hormones:
https://pubmed.ncbi.nlm.nih.gov/25201798/
That looks less like neutral breathing space and more like the first step on a pathway.

You also say talk therapy does not “cure people of being trans”. That is a straw man. The point of proper psychological care is not to “cure transness”. It is to help a distressed child understand their distress, tolerate their body, explore autism, trauma, sexuality, anxiety, depression, family dynamics, bullying, body image and social influence, and ideally grow into an adult who can live peacefully in reality. High rates of co-occurring conditions are well documented; for example, studies report elevated rates of autism spectrum traits among gender clinic referrals:
https://pubmed.ncbi.nlm.nih.gov/26754056/
That is not conversion therapy. It is basic child mental health care.

Then you claim that the only thing shown by sound, reliable, repeatable science to relieve gender dysphoria is transition. That is simply not true. Especially for kids. Systematic reviews have repeatedly found the evidence base to be low quality and uncertain. The UK’s Cass Review interim report explicitly states that “the evidence base for interventions in this area is weak”:
<a class="break-all" href="https://webarchive.nationalarchives.gov.uk/ukgwa/20250310143633/cass.independent-review.uk/publications/interim-report/" rel="nofollow" target="_blank">https://cass.independent-review.uk/publications/interim-report/
NHS England subsequently stopped routine puberty blocker prescribing outside research settings due to insufficient evidence of safety and effectiveness:
https://www.england.nhs.uk/2024/03/nhs-to-stop-routine-prescription-of-puberty-blockers/
The Finnish study is also important. It found that once psychiatric treatment history was accounted for, clinical gender dysphoria did not independently predict suicide mortality:
https://pubmed.ncbi.nlm.nih.gov/32345113/
In other words, the serious issue is psychiatric morbidity. These are vulnerable children with mental health needs. That supports careful whole-child care, not rushing to suppress healthy puberty.
And the ethical point remains.

Research is not automatically moral because it produces evidence. Children are not test subjects for adult theories. You need a plausible benefit and an acceptable risk-benefit balance.

Here, the benefit is unproven. The harms are serious and documented: effects on bone density, potential impacts on fertility, and unknown long-term neurodevelopmental consequences:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759272/
The child cannot meaningfully consent. And the intervention does not and cannot solve the underlying claim, because no drug can make a child the opposite sex.

So no, “the family and clinicians decide” is not enough. Families and clinicians can be wrong. Entire medical systems can be wrong. That is why safeguarding, evidence, ethics and law exist.

Stopping a healthy child’s puberty is not a benign pause. It is a major medical intervention with lifelong stakes. Dressing that up as “time to think” does not make it safe, neutral or ethical.

i am staggered you want to do these things to children.

Out of curiosity @Zoonosis : what level of harm (physical or mental) would you actually find unacceptable in this trial? Is there any outcome whatsoever that would make you decide that puberty blockers should not be given to children?

Zoonosis The only thing which has ever with sound reliable repeatable scientific evidence been shown to relieve gender dysphoria is allowing people to transition.

Have you taken 'the passage of time' into account in making this claim?
Children tend to grow out of gender dysphoria:

Three developmental trajectories of gender non-contentedness were identified: no gender non-contentedness (78%), decreasing gender non-contentedness (19%), and increasing gender non-contentedness (2%)....
Gender non-contentedness, while being relatively common during early adolescence, in general decreases with age.
Rawee P, Rosmalen JGM, Kalverdijk L, Burke SM. Development of Gender Non-Contentedness During Adolescence and Early Adulthood. Arch Sex Behav. 2024 May;53(5):1813-1825. doi: 10.1007/s10508-024-02817-5. Epub 2024 Feb 27. PMID: 38413534; PMCID: PMC11106144.

I missed the end of the debate as I had to go out. What was the result?

Surely the basis of any trial should be that there is evidence of benefits, then you do a trial to see if the harms outweigh the benefits.

In this case, there is no evidence of benefits to start with. We don't just put patients, and especially children, through random shit just in case it might help.

"It may be that if they were prescribed puberty blockers instead, that would give more time for the therapist to work with them and perhaps come to a different solution than a long-term life on medication."

Anybody else getting flashbacks to about 2017?

I thought even the Tavistock conceded years ago that 'time to think' was not how these drugs work.

The main rationale for going ahead with the PB trial seems to be that if PBs are banned children will just access illegal cross sex hormones. That is not a valid reason for a clinical trial.

I also doubt many 11 and 12 year old are sourcing hormones themselves

The puberty blocker drug used in the US is Lupron, which has been used to block precocious puberty in young children as well as in trans-identifying teenagers. It's also used as a prostate cancer drug and to treat endometriosis.

But it's a drug with known harmful side-effects, and it has been the subject of class action lawsuits. There's more detail here:

https://porterprotects.com/do-i-have-a-lupron-lawsuit/

So even though in precocious puberty, puberty blockers are perceived as doing more good than harm, the harm isn't trivial. There is of course absolutely no reason to prescribe them to gender-questioning 12-year olds.

Cass believes without a trial young people will continue to get drugs from "unregulated and dangerous routes."

So what happens if we do the trial and, as expected, puberty blockers cause a lot of harm for little or no benefit? Will young people say OK, I'll stop buying dodgy drugs online, or will we need to keep prescribing regardless of evidence to prevent them from turning to unregulated and dangerous routes?

This is kicking the can down the road. It's not an argument for a trial it's an argument for just giving vulnerable children what they want even if we know it's harmful because they'll find a way to get it anyway.

Even if you think there's a strong harm reduction argument for doing this, the trial would make no difference so we shouldn't do it.

I hate to be the Godwin making the obvious parallel on this thread, but that protocol was used in the 1940s. Anyone who thinks that "try it and see what happens for shits and giggles" is a robust methodology to replicate today is either equally insane or has some very dark ulterior motive.

Government voted to proceed with the trial 283 to 112.

IMO Cass believes that the trial will demonstrate some harm, and so most parents (whether their children are on the trial or not) will then stop sourcing the blockers for their children and allow them to experience a normal puberty. She thinks that the parents who continue to demand blockers will self-evidently be the ones whose children are 'true-trans' and so, for them, any harms will be outweighed by the 'benefits'.

However, I think she has been played by the activists who are setting up a trial that will show short term positives while not investigating medium and long-term harms.

God why

Whilst I oppose the trial I fear it will go ahead. Like @HenriettaSwanLeavitt I am concerned that this is not a longitudinal study as the lifelong impact needs to be documented.

I do wonder if a concession of making it a long term study with key reporting points e.g. 5 years, 10 years etc. maybe more achievable.

The time I was prescribed them for endo was horrific, the physical mental and emotional effects of them were devestating and still, over 20 years later, leave me feeling physically sick at the thought of young children being given them.

The premature menopause and osteoporosis are no fun either.

Good question. The quality of the govt’s arguments (sad octogenarian transwoman constituent…) left a lot to be desired.

Really sad. Culpable adults.

During this vote, party lines were largely maintained. Labour MPs voted down the motion to scrap the trial, while the Conservative party and several independent MPs pushed for its outright cancellation

There was also a fair bit of “but you Tories commissioned and accepted the Cass report so ner”. Pathetic.