Prescribing evidence: Combatting anti-scientific policies on puberty blockers

The process of transitioning, and transgender-affirming health care, can be a confusing experience from an outside perspective. Most people are not trans or gender diverse (TGD), and thus will never have any first-hand experience when it comes to transitioning. However, some of the early steps of a medical transition are not exclusive to TGD people.

Puberty blockers are crucial to these first steps, though policy and public perception often are not shaped by the science. A medical transition is not necessary to be considered TGD. Being TGD is unique to each individual; it is impossible to generalize and can include non-physiological aspects of gender expression such as fashion, socialization, and use of a preferred name or pronouns.

My decision to write this article was inspired after reading a piece published in Healthy Debate: “Prescribing compassion: Standing up against transphobic policies in Alberta”. The authors expressed concerns about how transphobic policies may affect TGD youth. While this article was focused on policies specific to Alberta, we need to explore the issue on a broader scale as these types of policies are appearing globally. I share the authors’ call to ensure the policies we enact are based on evidence, and not on personal views about potential slippery slopes.

While reading the article, I noticed that some of the sentiments discussed, in this case by Alberta Premier Danielle Smith, were shared by several commenters below the post. The primary theme was that puberty blockers are not a reversible intervention. In response to these sentiments, which are driven by personal perspectives, the facts of the matter must be clearly articulated. The science is clear. The use of puberty blockers is a reversible method that allows TGD youth (and others) to explore their gender identity, and it is clear that these medical interventions are safe and effective. In fact, they are so safe and effective that medical practitioners prescribe puberty blockers to cisgender youth who are going through precocious puberty.

Precocious puberty is when a child begins exhibiting the characteristics of puberty at an age earlier than typically expected. In these cases, puberty blockers, often leuprolide acetate or triptorelin, may be prescribed to prevent the production of sex hormones triggered by the start of puberty. As a result, the physiological effects of puberty are halted. However, the beginning of the hormone pathway is not blocked by these interventions, and can be restarted by stopping the intervention. Therefore, the effects of puberty blockers are entirely reversible. Youth (and their guardians when applicable) who are concerned that their puberty is beginning too soon can acquire these treatments to pause the pubescent physiological changes until they are ready for them to start. This is the very definition of gender-affirming medical care. Someone is taking action to ensure their physiology aligns with their experience of their gender. It is entirely plausible that an 8-year-old boy growing pubic hair or a 6-year-old girl menstruating would want to experience these changes at the same time as other youth as opposed to having their childhood rushed. I have rarely seen pushback from people opposed to puberty blockers in these cases, or in any policy to prevent cisgender youth from accessing these interventions.

However, there seems to be a push to block access by TGD youth.

When looking at the issue, even from a trans-exclusionary point of view, the facts of each case are nearly identical. In both circumstances, a person/patient is concerned about puberty commencing and is seeking a solution to give them the time to decide how to proceed. In these simplest terms, the primary motivation is the same. Why then, will cisgender-conforming youth have the luxury to undergo these treatments while TGD youth will not?

Additionally, the distress caused by undergoing undesirable pubescent changes is shared among both groups, albeit at possibly different ages. Thus, why should we deny relief to one group and not another, based alone on their gender identity?

The compassionate and evidence-based answer is clear. There should be no additional restrictions for TGD youth seeking this treatment. Across the board, access to this treatment greatly benefits these youth and is only bettered by the fact that it is reversible.

It is not the case that TGD youth are seeking these treatments for reasons not shared by cisgender youth. Both groups are attempting to ensure their physiologies align with their preferred expression of gender, whether that be based on timing or identity, and ought to be treated equally.

Most crucial is the distinction between puberty blockers and hormone replacement therapies (HRT). Puberty blockers are, as mentioned, a reversible medical intervention to allow TGD youth the time they need to understand their gender identity before puberty takes its irreversible toll. HRT, however, is a later stage of TGD health care that involves supplementation of hormones that align with the desired gender expression of the patient. This allows for physiological changes that move away from the gender assigned at birth and toward their current, correct gender identity.

Thus, these two interventions are very different, and both may not be necessary or applied in each situation. It is pertinent to mention, however, that HRT is much more easily accomplished if someone has been on puberty blockers since they would have a blank slate on which the supplemented hormones can operate. Puberty blockers are a safe and reversible option to give TGD youth the time they need to explore their gender identity; views on the use of HRT for this group should not affect the availability or policy surrounding puberty blockers.

Although the evidence around puberty blockers is clear, policy is in motion in Alberta and the United Kingdom to prevent their use by TGD youth. Alberta Premier Smith has stated that puberty blockers would not be prescribed to youth under the age of 16. Furthermore, the Cass Review, the new standard for TGD care in the U.K., has banned puberty blockers for anyone under the age of 18. Both of these prohibitions are targeted at TGD youth, with no mention of restriction to cis youth as a treatment for precocious puberty. These are just two examples of how cis-normative claims with a lack of evidentiary substance can turn into dangerous policies targetting an incredibly vulnerable population like TGD youth.

If we are to comply with these policies, we would not only be harming these youth but would be doing so in the face of contrary evidence. As has been shown many times, puberty blockers are safe and effective and provide a reversible method for TGD youth to explore their identity before puberty can take effect. To prevent only TGD youth from using these interventions would contradict the evidence and would be an unjustifiably discriminatory act.

The Cass Review says allowing access to puberty blockers may prompt TGD youth to move forward with affirmative hormone therapy, which is tantamount to a slippery slope fallacy. This is not the only case in which such a fallacy is invoked, often appearing where other anti-trans policies are posited. Thus, not only do these policies lack evidence, but they also provide fallacious reasoning for their bigotry.

None of the policies preventing puberty blockers can be justified, as they are entirely discriminatory. Unless puberty blockers are banned for all youth – which would be reckless and opposed to my personal views on the matter – it must not be the case that only a minority of youth should be denied the opportunity to access them.

If cisgender-affirming care is on the table, then transgender-affirming care must join it.