The fierce debate over puberty blockers has become a collision of science and politics. To try to address a fractured consensus, the federal government is attempting to lay the groundwork for a national standard.
Advocates argue pausing puberty temporarily — for months or a few years — buys patients time to decide if they want to take the next steps towards transitioning with hormones.
But critics say the medication is experimental and potentially dangerous, with questions over whether children have capacity to consent to the treatment.
More than half of US states now have policies banning or restricting the treatment for minors.
Other countries like the UK, Finland and New Zealand have also restricted the use of puberty blockers.
The UK’s ban for new patients followed the Cass review into gender-affirming care offered by the National Health Service (NHS) in England, which called for sweeping changes to the treatment of young people with gender dysphoria.
Conducted by paediatrician Hilary Cass, the review found the evidence base for treatments like puberty blockers was “weak” and there was insufficient evidence about the effects of the medication on fertility.
It also found bone health might be compromised during treatment.
A clinical trial known as PATHWAYS had been planned to gather further data, but it has been delayed because of safety concerns and legal challenges.
In Australia, politicians are divided.
Queensland last year became the first state in Australia to restrict public access to puberty blockers for children with gender dysphoria who were not already on them.
The Northern Territory followed suit.
As it paused access to the medication, Queensland ordered an independent review by psychiatrist Ruth Vine.
The review found overall that the evidence base about the use of puberty blockers for gender dysphoria was limited.
On the issue of the impact of the treatment on fertility, it also found the evidence was limited.
Based on the available research it found there was evidence that puberty blockers “impact bone health in the short to medium-term”.
The review found that while the long-term physical, mental health and social impacts of prescribing puberty blockers had not been settled, the risks should be balanced with an emerging trend of evidence suggesting potential psychosocial benefit.
It stated the “effects of [puberty blockers] are reversible” and with proper oversight … “there can be benefit for a young person” in accessing the medication.
The review put forward three options for the Queensland government.
The first banned puberty blockers or hormone treatment for gender dysphoria in the public system for children under the age of 18, an option it said carried “inherent risks” including treatment being provided privately without multidisciplinary care.
The second would return Queensland to the situation before the ban, where treatment was provided through the Queensland Children’s Gender Service. The review said this option may be beneficial for young people but also carried risks, including a limited evidence base for the medication.
The third would allow the treatment to be delivered within a public statewide system of care, with additional safety measures to help ensure and monitor quality of care and mitigate risks. The review said that option would “support more robust research and reporting to inform the evidence base”.
The Queensland government stopped short of fully implementing the first option, instead choosing to continue the pause until 2031, while awaiting the results of the upcoming UK clinical trial.
Professor Cheung argues that a burden of proof has been put on puberty blockers that has not been placed on other forms of health care.
However Gold Coast paediatrician Dylan Wilson says he does not believe the benefits outweigh the risks.
“The fact that this has been subjected to systematic reviews shows that the evidence at the moment is poor,” he said.
Queensland’s effective ban has led many children with gender dysphoria to Brisbane GP Fiona Bisshop.
Dr Bisshop, a past president of the Australian Professional Association for Trans Health, now administers puberty blockers to patients paying about $3,000 a year to purchase the medication privately.
Dr Bisshop says puberty blockers have benefits that outweigh the risks for many young people, and they minimise the need for future medical intervention for those who decide to continue with their gender-affirming care.
Queensland Health Minister Tim Nicholls defended his government’s decision.
“We owe it to children to ensure health care is based on robust evidence and delivered with caution to ensure their safety and wellbeing,” he said in a statement to 7.30.
Clinicians prescribing puberty blockers argue only a small portion of patients referred to gender clinics go on to puberty blockers.
However, finding out exactly how many children are on puberty blockers for gender dysphoria is difficult, and has meant people are debating an issue without relevant data.
7.30 contacted every state and territory for the figures, however most declined to provide the information, citing privacy concerns, even though the data could be provided without naming individual children.
Perth Children’s Hospital’s Gender Diversity Service is treating 58 children on puberty blockers, while Queensland’s Children’s Gender Service, which is not taking new patients, is treating 77 patients with puberty blockers.
Dr Wilson says the lack of transparency about how many children are on puberty blockers nationwide is problematic.
The Australian Medical Association (AMA) supports the use of puberty blockers for children with gender dysphoria.
Dr Wilson is among those who believe they should not be used.
“I think children should be allowed to grow and develop, become who they really are, allow themselves and their identity to mature, allow their bodies to grow and mature, be helped and supported and loved through that difficult period of time with the appropriate mental health support that they need, without making any permanent irreversible decisions about their bodies,” Dr Wilson said.
While the available studies indicate puberty blockers are reversible, Dr Wilson points to international research and anecdotal evidence in Australia that suggests the majority of children who start on puberty blockers choose to go on to hormones like oestrogen or testosterone.
“It’s only reversible if they are actively reversed. So children have to come off them and allow that time for the body to resume normal puberty in order for that to happen,” he said.
For puberty blockers to be as effective as possible, they need to be taken early in puberty. For some children that happens as young as age 10.
Psychiatrist Philip Morris, who does not treat children with gender dysphoria, questions whether a child so young could appropriately consent to treatment.
Professor Morris is the president of the National Association of Practising Psychiatrists (NAPP), a group which has written a guide for clinicians advocating for puberty blockers to be “second-line” treatments, with psychotherapy to be used as a “first-line” intervention.
As it considers the patchwork of policies and processes both internationally and at a state level, the federal government has asked the National Health and Medical Research Council (NHMRC) to develop new national treatment guidelines for trans and gender diverse youth in Australia, including around the provision of puberty blockers.
The final guidelines are due in 2028, with an interim report due in a matter of weeks.
[Ed: This article fails to profile any of the increasing numbers of ‘detransitioners’ – individuals who deeply regret these medical interventions and are beginning to sue for medical negligence.]
Source: National guidelines on puberty blockers coming as fraught debate continues – ABC News