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I got into an argument on JK Rowling recently. That was mildly annoying, but then it shifted to transgender stuff in general, and the puberty blocker discussion in particular was very vexing to me. I just genuinely don't know how anyone can be okay with the idea, especially now that we know way more about it than we did 10 years ago. The dismissal of the Cass Review on the part of the pro-trans side has increasingly looked like the stereotypical right winger doing mental somersaults to any science they dislike. But I have some questions on it, there were some things I didn't have great answers to.
What are the actual requirements for getting prescribed puberty blockers? The pro-trans tribe insists that it is a very rigorous process involving thorough checking of gender dysphoria, and it's not commonly done, despite being a readily available tool in the toolbox of clinical practice. I do not believe this after examples I have seen, but I have nothing to cite.
Is there any actual scientific evidence in favor of social contagion playing any part in transgenderism? The pro-trans tribe claims that social contagion plays no role, and to me, it's trivially true that social contagion plays an astounding part, as well as fetishism and abuse, and autism. I have no idea how many kids genuinely become gender dysphoric due to genetics, if there are any at all. And if there are any, I certainly don't think that it's a given that they need puberty blockers. How the hell did that become the default? But anyway, has The Science turned up anything on social contagion?
Are there any actually valid critiques of the Cass Review? Pro-trans tribe will cite the Yale Law retort, then when I point out the responses to it, either holes are poked in them or they just go back to their priors that the Cass Review was methodologically bad, done by a transphobe, misinterpreted studies, and went against the scientific consensus and ruined its own credibility. Actually, they say the same about the recent HHS Report. Please show me if there are any published valid critiques of the Cass Review besides the Yale thing.
What are the probabilities of serious consequences from puberty blockers? I brought up infertility, and the pro-trans tribe claimed that it's actually a very low chance and that it's not anyone's business anyway because not everyone wants to have kids. The latter half of that is completely inane when we're talking about life changing decisions for a demographic that cannot consent, but the former, I don't know. Do puberty blockers cause the infertility, the loss of ability to orgasm, and the complete lack of penis tissue with which to create a neovagina, or is it the ensuing hormones that do this?
Sadly, none of this will do anything to convince anyone on either side anyway. There's really no way out of this hole that has been created. Sometimes, I kind of hate this world. I really thought "don't give minors seriously debilitating life changing pills to solve a solely mental disorder" was an easy hill to stand on, but the fighting was just as vicious as anything else with the gender issue.
Edited to be slightly less angry.
I think there's a lot of clinical discretion so it varies. I remember reading news articles about some prescribing them after a single appointment that you could try to look up, and here's an extreme example in Canada from a couple years back, where the "Gender Pathways Service" advises family doctors on prescribing them before a single appointment with a specialist:
If they're willing to do that presumably they are also willing to hand them out readily themselves.
Copy-pasting the last comment I wrote regarding the state of the evidence for puberty blockers:
Puberty blockers both lock children onto the transgender pathway (making them largely equivalent to prescribing HRT in actual outcome) and have very serious and poorly-studied medical consequences of their own, including potential damage to brain development. In children the "watchful waiting" approach used to be standard, meaning the children were not given any "gender-affirming" medical or social intervention, just treatment for whatever other psychological issues they had. Did they continue to want to transition into adulthood or did their gender dysphoria desist on its own? Some studies on this were conducted, and according to this meta-study and this blog post the desistence rates they found ranged from 61% to 98%. If you just add the figures from the studies listed in the linked study it would be an overall desistence rate of 85%, or 80% for the studies listed in the linked blog post. By contrast 97% of children put on puberty blockers go on to take hormones (page 38). The lack of any randomized control study makes it difficult to be sure, but this seems indicative of a very strong "lock-in" effect.
The lock-in from social transition also seems very strong even for children not on puberty blockers (and may be a large part of the lock-in associated with puberty blockers), with this study finding the persistence rate of "binary transgender identity" to be 94% 5 years after social transition. The study mentions that persistence was less common for children that were transitioned before the age of 6, which significantly affects the results because they were 124 of the 317 children in their study, but still 90.3% compared to 96.4% for those 6 or older. 5 years isn't really long enough to know long-term desistence of course, but the explosion in rates is recent enough that it would be difficult to do much longer.
Meanwhile regarding the side-effects of puberty-blockers themselves there is very little high-quality evidence (e.g. randomized control trials in humans that track the things you want them to track), and essentially none for using them to avert puberty entirely rather than stop precocious-puberty for a few years. But this randomized study in sheep seems to indicate permanent damage to brain development:
In humans the best we have seems to be this study in which a 3-year course of puberty blockers in girls with precocious puberty is associated with a 7-point reduction in IQ from what they scored before beginning the puberty blockers. However without a randomized control trial and/or a longer-term followup it is difficult to know if this is meaningful, which is why I mentioned the sheep study first.
The NHS's independent review mentions a similar concern:
This all seems completely backwards and the opposite of the precautionary principle. A treatment as far-reaching and poorly-understood as preventing puberty should not be adopted as standard practice without conducting the research required to know if it is safe and effective. It should not be critics of the treatment looking through sheep studies and comparing desistence rates between different studies to find indications that it causes brain damage and treats gender dysphoria worse than doing nothing. It should be advocates having to do randomized control trials showing it actually improves outcomes relative to no treatment and that the damage to brain/bones/etc. is minor enough to be worth it. (In the U.S. it doesn't have to pass FDA approval because it's an off-label usage of drugs approved for precocious puberty. Unsurprisingly the trials conducted for that have little relevance to the way it is used for gender dysphoria, and frankly seem pretty questionable even for precocious puberty.) Instead it might be difficult or impossible to get ethics approval for such a study, since you're denying a now-standard treatment, particularly if you actually do it properly by advising your control group to not socially transition either. Since Sweden, Finland, Norway and the UK have in recent years advised against most or all usage of puberty blockers to treat gender dysphoria, hopefully someone in one of those countries will be able to conduct a proper randomized control trial?
It’s tough, but I don’t think RCTs are possible. Despite obviously how helpful they would be. They require you to randomize treatment, and not only is blinding difficult or impossible, at its core for an RCT to even occur you need parents and teen subjects BOTH who are willing to give up the choice entirely to chance! That is, if you’re assigned to a transition group or not, neither the parent nor child can have a veto, or it ruins makes random assignment useless. I don’t know anyone who would be comfortable doing that, do you?
That's why I suggest doing them in one of the countries that no longer recommends puberty-blockers - the choice would be between a 50% shot at blockers as part of the study or a ~0% shot as part of the general public. Theoretically some could go doctor-shopping internationally, but hopefully not enough to ruin the study. An unblinded RCT would still be a huge step up from the evidence we have now.
This will never happen, even if tried, these days you can get your bathtub Estradiol from Discord weirdoes (shout out to Keffals) or straight from India/China. A determined teen with a 50% legit chance would definitely supliment themselves to ensure their chosen outcome.
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