Tag Archives: GnRh agonist

Lupron: What’s the harm?

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Worried Mom and her son, Worried Brother, co-wrote this post.  Worried Mom is an attorney who currently works in the non-profit area, and Worried Brother is employed in the pharmaceutical industry, with a background in chemistry.  This piece is sourced in the scientific literature; click superscripted footnotes to follow links.

For recent mainstream coverage about the potential harms of pubertal suppression, see here and here.

by Worried Mom & Worried Brother

Before we can have a sensible discussion about Lupron and its hormone-suppressing effects, it is important to understand what normal hormonal balance means in a healthy teenager or adult.

Normal body functioning requires a certain latent amount of testosterone and estradiol (estradiol is the major estrogen in humans).  Men and women both have some of these hormones naturally present in their bodies, produced by testes in men and ovaries in women.  Testosterone is involved in the development of muscle bulk and strength, the maintenance of proper bone density, the creation of red blood cells, the sleep cycle, mood regulation, sex drive, hair growth, and cholesterol metabolism.1,2,3  Low testosterone levels can lead to deficiencies in any of these areas.  For example, lack of testosterone can cause fatigue, insomnia, and interference with mood and sleep, together with a host of other impacts on, for instance, a person’s sex drive.

Like testosterone, estradiol is involved in the maintenance of proper bone density, mood regulation, skin health, and reproductive health.4,5,6  Lack of estradiol can lead to adverse impacts in those areas.  Because estradiol is a crucial component in maintaining bone density, individuals who lack sufficient amounts of estradiol will fail to undergo proper bone development, because the growth plates on the ends of the bones will never close.7  This profoundly alters the physical structure of the body.

Lower levels of estrogen are also associated with significantly lower mood.  The primary regulators of mood in the brain, according to our current understanding of neurochemistry, are the systems relating to the neurotransmitter serotonin.  Estrogen receptors are prevalent along the mid-brain’s serotonin systems, and they are believed to play an important role in serotonin-mediated behaviors such as mood, eating, sleeping, temperature control, libido and cognition.  Mice that are bred missing this particular sub-type of estrogen receptor show enhanced anxiety and decreased levels of serotonin and dopamine.8

As noted, both men and women naturally produce testosterone and estradiol in their bodies.  The levels of these hormones fluctuate greatly depending on the person’s stage of life.  At the start of puberty, a child’s body will begin to produce either testosterone or estradiol in much greater quantities than it had previously.  This increased production leads to the development of secondary sexual characteristics.  As men and women age, their levels of testosterone and estradiol also decrease, leading to well-known age-related effects, such as thinning bones and hair in both men and women.

A current focus in the treatment of transgender children and teenagers is to arrest, or delay, the impact of testosterone and/or estradiol in adolescence.  Arresting the impact of these hormones will prevent the development of secondary sexual characteristics.  Moreover, many clinicians recommend–if a child or teen is unsure as to whether he or she wishes to become a transgender adult–that the administration of so-called “blockers” will “delay” puberty and “buy time” for the teen to make a more informed or mature decision.  Theoretically, a teen could always desist from taking blockers and then normal puberty would ensue, although there is very little data in this area.  It is also currently unknown whether, if a teen takes a puberty blocker during what would otherwise have been his or her normal puberty and then stops, whether puberty will proceed entirely as normal or whether there will be some other effects from having delayed it for a period of years.  The “puberty blocker” discussed in this article is leuprolide acetate, better known by its trade name Lupron.

What is Lupron?  Lupron is a gonadotropin-releasing hormone analog.  The primary pharmacological effect of Lupron administration is a decrease in the concentrations of testosterone and estradiol throughout the body.9,10  How does it achieve this decrease?  It does so by tinkering with a hormonal feedback loop between the hypothalamus and the pituitary gland, and interferes in the release of gonadotropins (“Gn”), which is a catchall term for 2 separate hormones, luteinizing hormone (LH) and follicle-stimulating hormone (FSH).  Gn acts as the primary means by which the body controls the release of testosterone and estradiol.  Gn interacts with the tissues that are involved with the release of these two hormones.  It stimulates specialized tissues in the ovaries and the testes to produce testosterone and estradiol.  LH stimulates the Leydig cells in the testes and the theca cells in the ovaries to produce testosterone11.  FSH stimulates the spermatogenic cells in the testes and the granulosa cells in the ovarian follicles (the granulosa develop to produce a layered structure around the egg), as well as stimulating the production of estrogen by the ovaries12,13,14. There are Gn receptors embedded in the cell membranes of these tissues and binding with Gn results in those tissues producing the hormones.  The hormones are released into the bloodstream, and travel to specialized receptors that are located systemically, in most major tissue groups.  The systemic distribution of these receptors is responsible for Lupron’s effect on the entire body.

The hypothalamus releases GnRH (Gn-releasing hormone) which binds with GnRH receptors on the pituitary gland15.  The hypothalamus responds to the concentrations in the blood of testosterone and estrogen, as well as the presence of Gn16,17.  Since Lupron is chemically similar to GnRH, it is essentially repeatedly stimulating the GnRH receptors on the pituitary gland.  This artificially high activation of these receptors desensitizes the pituitary gland to the presence of GnRH18.  There is an initial flare-up of Gn release in response to the presence of the Lupron, but it eventually results in down-regulation or deactivation of these receptors19.  In physical terms, this means that the pituitary, in an effort to restore normal functioning, will cull the number of GnRH receptors.  This results in a significantly lowered response to a given concentration of GnRH in the blood. Why is this?

This is the key point, because the strength of an organ or tissue’s response to any drug is directly proportional to how many receptors are activated by the presence of the drug.  So, using this idea, lower the number of receptors, lower the response, and if there is an absolutely lower number of receptors present, there is an absolutely lower potential response20.  Once the drug is removed from the body, the pituitary is left in a desensitized state, rendering it unable to respond to ‘normal’ activation by GnRH.  This results in decreased production of Gn, which in turn means decreased production of both testosterone and estradiol in the tissues with which Gn would normally interact.

Lupron use in otherwise normal teenagers to delay puberty is both relatively new and off-label.  Lupron does have a history in treating a condition called ‘precocious puberty,’ which is what happens when a child’s body enters puberty too quickly for his or her age.  However, this is a clinical condition typified by concentrations of sex hormones deemed wildly abnormal in the course of normal development.  As such, the usage of this drug may be more appropriate in  these particular individuals, because the marginal benefit of leaving this condition untreated is higher than it would otherwise be. Any competent medical professional would not generalize from outcomes observed in a population of individuals affected by abnormal hormone levels, to individuals with normal hormone levels.

Industry standards21 judge the usage of Lupron in treating gender dysphoria as providing at best no proven benefit and hold that there is an insufficient quantity of published evidence to prove its safety for this purpose.  UnitedHealthcare, the nation’s largest insurer, makes its stance clear on Lupron for usage in treating gender dysphoria on their Drug Policy page:22

‘Hayes compiled a Medical Technology Directory on hormone therapy for the treatment of gender dysphoria dated May 19, 2014.  Hayes assigned a rating of D2, no proven benefit and/or not safe, for pubertal suppression therapy in adolescents. This rating was based upon insufficient published evidence to assess safety and/or impact on health outcomes or patient management.’

A D2 rating is the lowest rating possible on that particular institution’s scale of safety and efficacy.  The Hayes Technology Review is considered to be the industry standard in linking treatments with patient outcomes.

In Lupron’s case, the vast majority of clinical data is found in samples of middle-aged or older men with late-stage prostate cancer.  This means the aggregate of the medical community’s understanding of Lupron’s safety profile relates to its use in this context, in terms of both the condition it is meant to treat and the individuals for whom it is approved.  When using Lupron as a “blocker,” medical professionals are, in both senses, treading untested waters, for the dual reason that it is not approved or recommended to “treat” this particular condition, and clinical studies relating to its long-term or even short-term safety in treatment of gender dysphoria are vanishingly rare.  To further illustrate this second point, the population to whom Lupron is most commonly prescribed on-label, middle-aged and elderly men, has a much shorter life expectancy from the date of administration than do teenagers.  In other words, based on the current state of research, one would not expect to see data collected from groups who are 40, 50 or 60 years “out” from administration.

Putting together what we know about how the body normally reacts and develops during puberty with what we know about how Lupron works, we can conclude the following: administration of Lupron to young people for the purposes of blocking puberty is a disruption of a delicate hormonal balance that has the potential to cause adverse health effects.  The risk is further compounded by the off-label usage of the drug for this purpose, as well as the lack of long-term data related to safety.

 

Blocking puberty–and the right to an identity crisis

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I recently wrote about research findings that gay and lesbian youth are typically older than their heterosexual counterparts when they first act upon and realize their sexual orientation. While same-sex attracted girls, in particular, reach this milestone between 19-early 20s, the current trend is to “socially transition,” then puberty block, and finally move on to cross sex hormones at age 16.

It’s easy to see that many of these teens are being set up to short-circuit the natural discovery of their sexual orientation. But is that the only potential problem with social transition and puberty blocking—the preemptive conversion of likely gay and lesbian youth to transgender?

Not by a longshot. There are so many important things that happen at puberty which are critically important to the maturation necessary to make informed decisions about major life changes (you know–things like sterility, loss of breasts, and a permanently deepened voice) that a developmental psychologist or cognitive scientist could write a doctoral dissertation about the subject.

In fact, many have; the research and clinical literature going back to the mid-20th century is chock-a-block with replicated studies, clinical observations, and meta-analyses. More recently, we have MRI and fMRI studies corroborating earlier observations.

What we don’t have, at least not yet, are the PhD theses showing how the experimental “treatments” currently being implemented by pediatric endocrinologists and gender specialists—many of whom have no professional background in child or adolescent psychology—fly in the face of that large body of literature.

I have spent hundreds of hours poring over the literature on gender dysphoria and pediatric transition. But in all the studies and papers I’ve read, I have not seen mention of the vast body of extant knowledge about child and adolescent psychology. It’s as if these gender specialists just started from scratch.

Erik-Erikson-portrait

Erik Erikson

What exactly are they ignoring? Well, for starters, there’s the work of Erik Erikson, a preeminent child and adolescent psychology expert of the 20th century. You can’t read the scholarly or clinical literature on pediatric psychology without finding a reference to Erikson’s work; in fact, much of the current knowledge in the field is built upon his fundamental insights. A blog post is not adequate to even summarize it, but his bedrock finding about the psychological journey of adolescence is this: Developing an identity takes place in stages, culminating in an integrated adult personality; and “identity work”—including an identity crisis—is critical to healthy adult psychological functioning.

erikson capAdolescent psychology expert James Marcia was another foundational thinker who built upon Erikson’s framework:

… two distinct parts form an adolescent’s identity: crisis (i.e., a time when one’s values and choices are being reevaluated) and commitment. He defined a crisis as a time of upheaval where old values or choices are being reexamined. The end outcome of a crisis leads to a commitment made to a certain role or value.

But we don’t need a study, a theory, or someone with a PhD after their name to prove this to us, do we? Any adult who has lived through that time of life called “adolescence” can attest to the fact that questioning, and trying on and discarding different ways of being, go with the territory. And it’s a rough time. How many adults would willingly relive the fraught and tumultuous days of middle and high school? Every psychologist (until the Age of the Trans Child) has agreed: it’s not supposed to be an easy ride. In fact, without the essential but painful work of adolescence, a person will not reach their adult potential: “unable to achieve an integrated adult identity, either because they have failed to resolve the identity crisis or because they have experienced no crisis. ”

Contrast this long-accepted understanding of adolescence with the approach taken by today’s gender specialists. Instead of helping children weather the natural and not necessarily comfortable process of cognitive and emotional development, they concretize and freeze in place the certainties of childhood, in what should be a time for exploration, not stasis.

It would be one thing if these gender clinics were really in the business of helping a child expand or explore different gender identities, without medical interference. But we know that they support and encourage “transition” from one sex to the other, with all the permanent physical changes that entails. In terms of adolescent psychological development, once these kids have taken the irrevocable step of moving from blockers to cross sex hormones, they have been denied the opportunity to go through an identity crisis.  So, a 16-year-old girl who has lost her fertility and her breasts, and who has already committed to a permanent testosterone-deepened voice and increased body hair — how easy will it be for her to experience James Marcia’s “time of upheaval where old values or choices are being reexamined?” That adolescent girl has been cheated of that stage of life. And when did we, as a society, decide that was a good thing?

The media stories and anecdotes from gender clinics are all the same: The kids are uncomfortable, so they and their parents seek relief. Then, according to everyone, the treatment “works” because the kids are happy. For how long? No one knows.

Be that as it may, an identity crisis isn’t supposed to be resolved in preschool, or kindergarten, or even middle or high school: It is the work and the challenge of adolescence, not complete until late adolescence.

 Adolescence has long been characterized as a time when individuals begin to explore and examine psychological characteristics of the self in order to discover who they really are, and how they fit in the social world in which they live. Especially since Erikson’s (1968) theory of the adolescent identity crisis was introduced, scholars have viewed adolescence as a time of self-exploration. In general, research has supported Erikson’s model, with one important exception: the timetable. It now appears that, at least in contemporary society, the bulk of identity “work” occurs late in adolescence, and perhaps not even until young adulthood.

“Late in adolescence”—after the time when most “trans” youth have moved on from puberty blockers to cross-sex hormones, thus bypassing the period when they would have been able to explore possibilities in their original bodies—including, but not limited to, their sexual orientation and other essential aspects of their identities and personalities.

The insights of the earlier child development experts have been corroborated by advanced visualization technologies, such as MRI and fMRI, which have revolutionized our understanding of the human brain and psychological development. In recent years, we have come to understand that full maturation occurs much later than previously thought.

Recent research has shown that human brain circuitry is not mature until the early 20s (some would add, “if ever”). Among the last connections to be fully established are the links between the prefrontal cortex, seat of judgment and problem-solving, and the emotional centers in the limbic system, especially the amygdala. These links are critical for emotional learning and high-level self-regulation.

Beginning at puberty, the brain is reshaped. Neurons (gray matter) and synapses (junctions between neurons) proliferate in the cerebral cortex and are then gradually pruned throughout adolescence. Eventually, more than 40% of all synapses are eliminated, largely in the frontal lobes. Meanwhile, the white insulating coat of myelin on the axons that carry signals between nerve cells continues to accumulate, gradually improving the precision and efficiency of neuronal communication — a process not completed until the early 20s.

In addition to reading research studies, I spend a fair bit of time reading the blogs, tweets, and social media writings of trans-identified teens. While most teens are pretty self-absorbed, with these kids, I am always struck by the depth of self-involvement, the extreme obsession with looks and appearance, and the constant focus on getting what they want, when they want it.

What is conspicuously absent in the narratives of many of these teens is another key aspect of pubertal maturation: self reflection and awareness. Concrete, literalist thinking is a hallmark of childhood. So a preadolescent frozen at Tanner Stage 2 of pubertal development (when blockers normally begin to be administered) may still think literally and concretely: “I am a boy.” Instead of: “Maybe I think I’m a boy because I like trucks and hate girly clothes. Maybe there’s a reason I think I’m a boy, but I’m really not.” The name for such higher level reflection, or “thinking about thinking,” is metacognition.

So when these young people, frozen at an earlier stage of cognitive development, are asked at age 15 or 16, “Are you SURE you’re really a boy?” why would any of them say “no”? And in fact, in the small number of studies that have looked at kids who have been socially transitioned and puberty blocked, none of them have failed to move on to cross sex hormones. Is this because they are “truly trans” and their clinicians have godlike diagnostic skills, with zero—zero!—false positives? Or is it because the very act of endorsing and reifying their self-proclaimed concretized self-images has helped them persist in those self-perceptions?

 No adolescent withdrew from puberty suppression, and all started cross-sex hormone treatment, the first step of actual gender reassignment.

It’s not just metacognitive and abstract thinking that develops slowly, reaching fruition in late adolescence. As I wrote about in this post, executive function—the ability to make decisions, plan, and think of future consequences (like, “do I want to have children of my own, ever”?) doesn’t begin to consolidate until the mid-20s.

Then there’s social maturity and a more nuanced understanding of how to interact with one’s peers. Who doesn’t remember the awkwardness, the trying-to-fit-in, seasick self-consciousness of adolescence? Social development takes place in concert with one’s peers, along with the slow dawning of self-reflection. A socially transitioned, puberty-blocked 14-year-old who has avoided the rigors of hormone-fueled social issues won’t  understand any of this.  How will that lack of experience inform their decision to continue on to cross sex hormones?

 We previously investigated how the ability to understand social emotional scenarios using mixed emotions varied across puberty in girls aged 9–16 (Burnett et al., 2011). There was a change between early and late puberty in the number of emotional responses that participants gave in social emotion scenarios, with girls in late puberty attributing a wider combination of emotions in social scenarios than their peers in early puberty

… Our findings of puberty-related changes in neural activation, together with those shown in other recent fMRI studies using different ‘social’ tasks as described in the introduction, suggest that aspects of functional brain development in adolescence, like these behavioral changes, may be more closely linked to the physical and hormonal changes of puberty than chronological age.

 As the authors note, social intelligence—a more nuanced understanding of “social emotion” scenarios—develops as a result of the release of hormones, not chronological age. This is so obvious it hardly seems worth studying (or proving on a functional MRI study).  Yet gender specialists talk as if the brain develops separately from the body; as if hormones are only important for secondary sexual characteristics. They are constantly reassuring skeptics that blocking puberty gives these incredibly immature kids the time to figure out if this is really what they want—without the benefit of the cognitive, emotional, and social maturation processes that comes with the secretion of pubertal hormones.

I’ve touched upon only a few facets of adolescent cognitive-emotional development in this post. The literature in this area is vast, still accumulating, and spans decades and millions of pages of writing. Contemporary cognitive scientists like Russell Viner, Sarah-Jayne Blakemore and Jay Giedd are continuing to add to the body of knowledge. But their work on adolescent psychology and brain development is not referenced in the media or in the writings of trans activists or pediatric gender specialists. In point of fact, what little peer-reviewed research there is in the field of “gender identity” is going in the exact opposite direction of the rest of developmental psychology and cognitive science—towards a reification of rigid, unchanging identity and decision-making “agency” for younger and younger children; while the replicated research of developmental psychology and neuroscience is moving toward an understanding of neuroplasticity, the necessity of undergoing an identity crisis, and a later age for brain maturation than was previously thought.

Cognitive scientist Jay Giedd:

One of the most exciting discoveries from recent neuroscience research is how incredibly plastic the human brain is. For a long time, we used to think that the brain, because it’s already 95 percent of adult size by age six, things were largely set in place early in life. … [There was the] saying. “Give me your child, and by the age of five, I can make him a priest or a thief or a scholar.”

[There was] this notion that things were largely set at fairly early ages. And now we realize that isn’t true; that even throughout childhood and even the teen years, there’s enormous capacity for change. We think that this capacity for change is very empowering for teens. …

Instead of respecting this “enormous capacity for change,” gender specialists are tampering with the endocrine system, freezing gender dysphoric children in a state of suspended development—and then expecting these psychologically and emotionally immature children to make permanent decisions about their future as adults. It’s a huge clinical gamble. What it amounts to is hoping for the best.

But is anyone preparing for the worst?

Skeptical ethicist: “A medical doctor is not a candy seller”

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candy seller

In yesterday’s post, I focused on the situation in the United Kingdom, where the school system is deeply enmeshed with a trans activist organization which peddles its message to kids as young as 4 years old. And the majority of posts on this blog document the seemingly unstoppable trend to diagnose and treat children as “transgender.” With this overwhelming level of societal and medical support, the issue must be pretty much settled—right?

Not according to the gender specialists themselves, it isn’t.

Hot off the presses, in the October 2015 issue of the Journal of Adolescent Health, a team of Dutch researcher-clinicians report findings from a survey of gender clinics which serve dysphoric children around the world.

Although you’d never know it, judging by the accelerating trend to socially “transition” kids as young as 3, freeze adolescents’ natural puberty with GnRh agonists, and then move on to chemical sterilization via cross-sex hormones thereafter, there is no  consensus amongst gender specialists that this current treatment protocol is the way to go.

The qualitative survey, entitled “Early Medical Treatment of Children and Adolescents With Gender Dysphoria: An Empirical Ethical Study” was conducted by a group of well-known Dutch researchers/gender specialists who are themselves actively involved in administering puberty blockers and other treatments to “transgender” children. The authors surveyed 17 treatment teams (endocrinologists, psychologists, MDs, psychiatrists, ethicists) regarding their views and experiences.

Many of the parents who contribute to and read this blog agonize about their difficulty finding therapists and doctors critical of the I’m-trans-if-I-say-I-am paradigm. I hope this post gives some measure of hope to those parents. While the skeptical specialists (nearly all of them psychologists or psychiatrists, with most endocrinologists and pediatricians apparently submitting pro-transition comments) are quoted anonymously, at least we know they’re out there. And enough of them exist to tell us that the runaway pediatric transition train may not have completely lost its brake pads—yet.

The journal article can be read in its entirety here, and the abstract summarizes the key findings:

The Endocrine Society and the World Professional Association for Transgender Health published guidelines for the treatment of adolescents with gender dysphoria (GD). The guidelines recommend the use of gonadotropin-releasing hormone agonists in adolescence to suppress puberty. However, in actual practice, no consensus exists whether to use these early medical interventions…

Seven themes give rise to different, and even opposing, views on treatment: (1) the (non-)availability of an explanatory model for GD; (2) the nature of GD (normal variation, social construct or [mental] illness); (3) the role of physiological puberty in developing gender identity; (4) the role of comorbidity; (5) possible physical or psychological effects of (refraining from) early medical interventions; (6) child competence and decision making authority; and (7) the role of social context how GD is perceived…

CONCLUSIONS:

As long as debate remains on these seven themes and only limited long-term data are available, there will be no consensus on treatment. Therefore, more systematic interdisciplinary and (worldwide) multicenter research is required.

Because my aim here is to show that gender specialists are not unanimously aboard the child transition bandwagon, this post will mostly highlight the comments from the more skeptical gender specialists surveyed. Amazingly (to me), the doubters seem to hit nearly all the same points I do in my blog posts.  [Note: Use of boldface to emphasize certain passages is my own, not that of the authors.]

So what is gender dysphoria?

Is GD a normal variation of gender expression, a social construct, a medical disease, or a mental illness? In the DSM-5 and the to-be-released ICD-11, the main challenge in classifying GD has been to find a balance between concerns related to the stigmatization of mental disorders and the need for diagnostic categories that facilitate access to health care, payment by insurance companies, and the communication between diverse professions.

I spend a fair amount of time reading articles and social media posts authored by gender specialists. It’s quite evident that there is currently pressure to completely de-stigmatize the transgender diagnosis…yet still find a way to get the “treatment” paid for by private insurance companies (or the taxpayer via public insurance such as Medicare or Medicaid). This thread from the WPATH public Facebook page [commenter names redacted] is illustrative of the dilemma the survey authors point to in the passage above.

wpath gender incongruence

So, this thread seems to indicate that providers are moving away from gender dysphoria as a disorder; even as an experience which causes distress. But why then would there be a need for medical treatment? This conundrum is addressed by the 17-clinic survey authors:

The interviews and questionnaires show that most informants find it difficult to articulate their thoughts about this aspect. Most see GD as neither a disease nor a social construct, but as a normal, but less frequent variation of gender expression. However, some note that you would not need medical procedures to make the lives of people with GD more satisfying if it were merely a normal variation.

Another thread from the WPATH public Facebook page seems to justify transition services for someone who just wants a “joyful and loving life.”

wpath joyful life

But when it comes to young people, at least one psychiatrist in the survey study gives us a less sanguine view of such quality-of-life justifications for medical transition:

“I find it extremely dangerous to let an adolescent undergo a medical treatment without the existence of a pathophysiology and I consider it just a medical experimentation that does not justify the risk to which adolescents are exposed. Gender dysphoria is the only situation in which medical intervention does not cure a sick body, but healthy organs are mutilated in the process of adapting physical and congruent psychological identity.” –Psychiatrist

I feel certain at least a few of the parents who frequent this blog wish they had the office phone number for this reasonable clinician. Amirite?

On the wisdom of puberty blockers

How many of us have asked, “but what if puberty blockers also inhibit the psychological/neurological maturation that comes with puberty–and beyond?” And, because many kids actually outgrow their gender dysphoria, interrupting puberty would deny them the opportunity to become comfortable in their bodies and avoid a life as a permanent medical patient.

It’s a pleasant surprise to see an acknowledgement of some of these concerns here:

In the literature, the concern is raised that interrupting the development of secondary sex characteristics may disrupt the development of a gender identity during puberty that is congruent with the assigned gender. The interviews and questionnaires show that some treatment teams share this view.

One clinician even talks about lesbian women who would have been misdiagnosed as “trans” children in an earlier time.

“I have met gay women who identify as women who would certainly have been diagnosed gender dysphoric as children but who, throughout adolescence, came to accept themselves. This might not have happened on puberty blockers.”–Psychologist

So at least one psychologist who works on a pediatric transition team acknowledges what many, formerly gender dysphoric women, say: that if there had been “gender clinics” for kids in the 1950s, 60s, 70s, or 80s, they would not be happy lesbian adults today, but sterilized “trans men.”

Speaking more broadly, another therapist has this to say:

“I believe that, in adolescence, hypothalamic inhibitors should never be given, because they interfere not only with emotional development, but [also] with the integration process among the various internal and external aspects characterizing the transition to adulthood.” –Psychiatrist

On co-occurring psychological/psychiatric issues

If you read through the part of this blog where most parents congregate and introduce themselves for the first time, some common themes emerge. One is the observation by many parents that their kids have other mental health issues, nearly always predating the (sometimes sudden) announcement that they are transgender.  While most activists insist that transition is the cure for what ails a dysphoric child or teen, the clinicians working in the trenches aren’t so sure.

The risk of co-occurring psychiatric problems in children and adolescents with GD is high. The percentage of children referred for GD who fulfilled DSM criteria of at least one diagnosis other than GD is 52%. The psychiatric comorbidity in adolescents with GD is 32%. Another study shows that 43% of the children and adolescents seen in a gender identity clinic suffer from major psychopathology. To date, the precise mechanisms that link GD and coexisting psychopathology are unknown.

Miscellaneous physical and psychological risks of medical transition

The surveyed clinicians acknowledge many of the concerns discussed regularly on this blog.

The possible consequences of suppressing puberty for cognitive and brain development are unclear and debated at this moment. The normal pubertal increase in bone mineral density may be attenuated by puberty suppression, and it is uncertain if there is complete catch-up after treatment with cross-sex hormones.

While it only merits one sentence (and no direct quotes), the surveyed clinicians appear to view sterilization as an important concern:

In the interviews and questionnaires, the loss of fertility was often mentioned as a major consequence of treatment.

And here’s an additional worry I haven’t seen in writing before: the potential negative impact of puberty blockers on future SRS surgery.

In addition, various informants stressed the importance of the fact that the penis and scrotum should be developed enough to be able to use this tissue to create a vagina later in life. Very early use of puberty suppression impairs penile growth and consequently makes certain surgical techniques impossible.

Will we see this rather thorny issue discussed on an episode of the Jazz Jennings reality show? Will the Tumblr trans activists screaming “now or never” take heed?

On whether kids are mature enough to make these decisions

One informant stated that the decision whether to start with hormones should only be made during adulthood: “We should facilitate his or her process of integration in the society and if he or she would undergo hormone- and surgical treatments he or she could decide [on this] during adulthood.” —Psychiatrist

Influence of the Internet and social media

You know how trans activists scoff at our observations that our kids only started talking about “transition” after binging on YouTube and Reddit?

They speculated that television shows and information on the Internet may have a negative effect and, for example, lead to medicalization of gender-variant behavior.

“They [adolescents] are living in their rooms, on the Internet during night-time, and thinking about this [gender dysphoria]. Then they come to the clinic and they are convinced that this [gender dysphoria] explains all their problems and now they have to be made a boy. I think these kinds of adolescents also take the idea from the media. But of course you cannot prevent this in the current area of free information spreading.” –Psychiatrist

Hello? The Advocate? The Boston Globe? The Washington Post? Anybody?

Furthermore, interviews and questionnaires show that treatment teams feel pressure from parents and adolescents to start with treatment at earlier ages.

Puberty suppression has been adopted as part of the treatment protocol by increasing numbers of originally reluctant treatment teams. More and more treatment teams embrace the Dutch protocol but with a feeling of unease…these professionals also have doubts because of the lack of long-term physical and psychological outcomes.

Hey, journalists. Obscure blogger over here quoting actual gender specialists, so you can’t say it’s just a bunch of nervous Nellie-moms making shit up. Need the link again? Oh, that’s just the abstract, here’s the pre-publication full-text, right here.

Self-harm/suicidal ideation

For several informants, a reason to use puberty suppression was the fear of increased suicidality in untreated adolescents with GD. Research shows that transgender youth are at higher risk of suicidal ideation and suicidal attempts. Nevertheless, caution is needed when interpreting these data because they do not show causality or directionality.

The meaning of that last sentence is crystal clear, and entirely in accord with what I, and other critics of the harmful “transition or suicide” meme that adult trans activists continually propagate, have tried to point out. While no one disputes that there is a higher self-harm and suicidality rate amongst trans-identified young people, there is no evidence that such self-harming behaviors and thoughts are ultimately alleviated by “transition.” Further, as this sentence implies, the “directionality” could be the reverse of what trans activists promote. Having a trans identity and/or facing the monumental prospect of medical transition could be a cause of self harming (in addition to the preexisting or comorbid mental health issues so many of these young people seem to have).

This is not the moment for another flippant call for journalists to take heed. This is deadly serious business: the terrible toll of self harm and suicide among trans-identified youth.  I have not seen a single news treatment of suicide or suicide risk that has even hinted at what these clinicians are stating baldly. Isn’t it time for a more nuanced discussion?

And finally: Leave it to a medical ethicist to point out the huge logical fallacy in the “informed consent” model of treatment now running rampant:

“The fact that somebody wants something badly, does not mean that a health care provider should do it for that reason; a medical doctor is not a candy seller.”— Professor of health care ethics and health law

Imminently sensible. So how is it that “informed consent” and the demonization of “gatekeepers” is more and more the norm? How is it that self identification as trans, even for young children, is fast becoming the only requirement for obtaining treatment? There is something strange going on here. If even some experienced gender specialists  are expressing doubts, why does the media behave as if the issue has been settled?

“The positive attitude of many health care providers in giving hypothalamic blockers…is based on the need to conform to international standards, even if they are conscious of a lack of information about medium and long term side effects.” –Psychiatrist

But how can there be “standards” (they are talking about WPATH here) that these providers feel pressure to conform to, if the standards are not based on solid information about risks and benefits? Exactly which cart is pulling this runaway horse?

As still little is known about the etiology of GD and long-term treatment consequences in children and adolescents, there is great need for more systematic interdisciplinary and (worldwide) multicenter research and debate.

Reason for hope?

The article concludes in a way that makes me feel a whisper of hope for the future.

Several professionals mentioned that participation in the study made them think more explicitly about the various themes, and it encouraged them to discuss the issues in their teams. In the Dutch teams, we therefore introduced moral deliberation sessions to talk about these ethical topics. The first reactions of the professionals were positive; the sessions made them rethink essential aspects of the protocol.

Will this “moral deliberation” and “rethinking” result in more caution, or even a desire to put a halt to the pediatric transition train? Time will tell, but it is encouraging that at least the Dutch researchers may be losing some sleep in pondering the incredible power they wield over the lives of children and their families.

At least we know there is controversy. At least we know they are not all marching in lockstep.

And that is something.