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Puberty blocking in gender dysphoria: suitable for all?
  1. Gary Butler1,2,3,
  2. Bernadette Wren2,
  3. Polly Carmichael2
  1. 1 Department of Paediatrics and Adolescents, University College London Hospital NHS Trust, London, UK
  2. 2 National Gender Identity Development Service, Tavistock and Portman NHS Foundation Trust, London, UK
  3. 3 UCL Great Ormond Street Institute of Child Health, London, UK
  1. Correspondence to Professor Gary Butler, Department of Paediatrics and Adolescents, University College London Hospital NHS Trust, London NW1 2PQ, UK; gary.butler{at}ucl.ac.uk

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We welcome the opportunity to comment on the concerns raised on the use of the hypothalamic blocker, the gonadotropin-releasing hormone (GnRH) analogue, to pause pubertal development in young people who have been assessed as having gender dysphoria and to extend the information presented in our recent review.1 It is important in the first instance to note that transgender identities have been documented across many different societies and historical time. Nowadays, more and more people are challenging the rigid articulation of sex and gender prescribed by many cultures and voicing an incongruity with their biological sex. Internationally, a meta-analytical study reported the prevalence of ‘transsexualism’ was 4.6 in 100 000 individuals: 6.8 for transwomen and 2.6 for transmen; time analysis found an increase in reported prevalence over the last 50 years.2 We may not understand exactly why this happens, but evidence from twin studies and brain differences, although tentative, suggests at least in part a biological component to gender diversity. To account for a strongly felt, unwilled, human capability like gender dysphoria, we probably need multiple-level explanations where the social and the biological intersect.

One of the principal impressions in meeting young transpeople is the frequent intense distress caused by the body they experience as incongruous and the changes that happen, especially at puberty. This intense distress is frequently associated with a documented increase in mental health difficulties. The task at the Gender Identity Development Service (GIDS) is to understand the complex ways in which young people may present—often with significant associated difficulties—to help them to maximise their developmental opportunities and to tolerate the distress of the perceived mismatch of body and gender feelings, while exploring the possible pathways available to them. At the GIDS we take care to be as sure as is possible that such distress can be attributed to the gender dysphoria, and not to other kinds of body dysphoria, anxiety, autistic spectrum functioning, other mental health states or illnesses, family dysfunction, or abusive environments. We support the importance of exploring how sexuality (including internalised homophobia) may be intertwined with an emerging sense of gender. Hence, as we described in our review,1 an extended and detailed assessment process is undertaken, despite the impatience of many young people and their parents/carers to move quickly to medical intervention. The young people referred to the endocrine clinic are thereby precisely the group most likely to ‘persist’ in their atypical gender identity as they have only been recommended for medical assessment following a thorough period of exploration in which the likely stability of their gender feelings has been established by the psychosocial team.

The reason for considering the use of GnRH analogue treatment (the blocker) is that we are balancing the distress in children with established gender dysphoria against the potential long-term risks of this treatment. Puberty onset is an important threshold as the intensity of the dysphoria changes and intervention has a significant effect on reducing this distress. Puberty blockade is only considered when the risks of non-intervention are considered the worse option in the patient’s best interest. Risks are always fully explained, including any potential effect on emotional development and decision making, and the effects on reproduction.

Studies tracking children and teens who receive hormone treatments show an encouraging picture of their good psychosocial functioning. Evidence from the Netherlands indicates that early pubertal suspension of sex hormones in a selected group of adolescents is associated with improved physical and psychological adaptation and well-being during adolescence and adulthood.3 Other case review studies indicate that young gender-variant people show psychological improvement on puberty blockers.4 There is little or no evidence of demonstrable harm from these interventions, although a study from Finland with a later-presenting, more troubled group of birth-registered female teens has shown these young people make few psychosocial gains on treatment.5 This is a group around whom we, as a service, are especially watchful.

With regard to the possible harms in the provision of6 cross-sex hormones, these relate less to their unknown physical impact over time, but rather to concerns about minors consenting to the irreversible bodily changes from these treatments, as well as from other (known) long-term consequences, including on fertility.

Our multidisciplinary staged approach is paced to ensure time for exploration of a range of possibilities and to ensure meaningful consent to any treatments. We do not go directly to prescribing cross-sex hormones, as is the practice in some European countries from age 15 years, and even as young as 14 years in the USA (N Skordis, G Butler et al, European Society for Paediatric Endocrinology survey of practice among treating paediatric endocrinologists 2017, Hormone Research in Paediatrics, in press). We do not think it is advisable without good supportive evidence to go straight into irreversible treatment. We know the blocker is reversible physically, buys time and reduces distress. We also do not know the comparable risks of being on cross-sex hormones, started early and continued for a lifetime.

What is most likely to lead to successful outcomes for patients, as far as current judgement allows, is a sensitivity to and respect for each patient’s life experience, an open exploratory stance towards complex causal pathways, an awareness of the relevant research and professional guidelines in considering options for care, and importantly a commitment to best ethical practice with respect to issues of safeguarding and consent. Extreme viewpoints, either liberal or conservative, do not help the arguments or promote science On the one hand, we have considerations relating to young people’s right to self-determination based on their intimate experience of profound gender incongruence and bodily distress. On the other hand, we have the responsibility to respect the shifting developmental dynamics of childhood, to understand any significant associated difficulties and to acknowledge the impact of powerful sources of social influence. Therefore, we continue to adopt a cautious ‘gatekeeping’ approach with detailed clinical scientific observation until we know more. 

References

Footnotes

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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