Ethics of Puberty Blockers

Learning Outcomes

  • Describes the diagnostic criteria and treatment options for Gender Dysphoria (GD) in young adolescents.
  • Differentiates gender non-conformity from Gender Dysphoria.
  • Analyses ethically relevant issues related to the treatment of adolescents younger than 16 with puberty-blocking hormones for GD.
  • Identifies relevant legal principles informing access to PBT and CSH for adolescent children with GD in Australia.

Ethics Task

  • Compare and critique ethically relevant arguments in two papers with different views on the best care for young adolescents with Gender Dysphoria.
  • Lecture provides background information for the tutorial.

Lecture Overview

  • Two case histories of young adolescents diagnosed with Gender Dysphoria (GD).
  • Diagnosis and management of Gender Dysphoria.
  • Australian and UK law.
  • Evidence-Based Medicine.
  • Set the scene for the ethics tutorial – summary of study to which the 2 tutorial papers are responding.

Case History 1: Georgie Stone

  • An Australian adolescent with Gender Dysphoria (GD).
  • Now a 22-year-old transgender activist.
  • Born one of twins, both male.
  • Diagnosed with Gender Dysphoria at age 7.
  • Puberty started at 10.
  • Supportive family.
  • Medical Treatment:
    • Stage 1: Puberty Blocking Treatment (age 11).
    • Stage 2: Oestrogen hormone therapy (age 15).
    • Stage 3: Surgery (age 19).

Terminology

  • Gender nonconformity: An individual’s appearance, behavior, interests, and self-concept vary from norms attributed to their biological sex, or from masculine or feminine general norms.
  • Transgender: An umbrella term describing the full range of people whose gender identity and/or gender role do not conform to what is typically associated with their sex assigned at birth.
  • Gender Dysphoria: Refers to a disjunction between an individual’s perceived gender identity and their assigned sex accompanied by severe psychological distress.

Gender Dysphoria in Childhood and Adolescence

  • Age 2-3:
    • Predominantly boys (historically).
    • May say they want to be, or that they are the other gender.
    • May be distressed by their primary sexual characteristics.
    • May play and dress in ways typically associated with the other gender.
    • Prevalence: 5-14/1000 boys, 2-3/1000 girls (from DSM-V).
    • 12-27% will have dysphoria that persists into adolescence and a continuing desire to be the other gender.

Diagnosis of GD for Children (Pre-Pubertal)

  • A GD diagnosis involves TWO clinical features:
    • A difference between one’s experienced/expressed gender (gender identity) and biological assigned sex (normal variant of gender expression).
    • Significant distress or problems functioning.
  • The duration of symptoms must be at least six months and there must be at least two of the following:
    1. A strong desire to be of the other gender or insistence that one is the other gender (or alternative gender to one’s assigned gender).
    2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing.
    3. A strong preference for cross-gender roles in make-believe play or fantasy play.
    4. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender.
    5. A strong preference for playmates of the other gender.
    6. In boys, a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls, a strong rejection of typically feminine toys, games, and activities.
    7. A strong dislike of one’s sexual anatomy.
    8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.

Puberty: A Critical Time

  • Majority of children diagnosed with GD desist.
  • Can exacerbate dysphoria in some children with GD.
  • Can trigger children without prior history of GD.
  • Rising prevalence in adolescence: 400% increase in Tavistock (referrals over 5-year period).
  • Greatest increase seen in biological girls in later adolescence.
  • Reasons unknown: Previously undiagnosed? New phenomenon?
  • Desistance rate in adolescence unknown (i.e., reverting to gender identity of biological sex).

Diagnosis of GD for Adolescents/Adults

  • A GD diagnosis involves 2 clinical features:
    1. A difference between one’s experienced/expressed gender (gender identity) and biological assigned sex (normal variant of gender expression).
    2. Significant distress or problems functioning.
  • The duration of symptoms must be at least six months and there must be at least two of the following:
    • A marked incongruence between one’s experienced/expressed gender & primary &/or sex characteristics.
    • A strong desire to be rid of one’s primary and/or secondary sex characteristics.
    • A strong desire for the primary and/or secondary sex characteristics of the other gender.
    • A strong desire to be of the other gender.
    • A strong desire to be treated as the other gender.
    • A strong conviction that one has the typical feelings and reactions of the other gender.
  • Although GD is in the DSM-V, it is not considered a mental health problem but rather is classified as a normal variant of gender expression.

What is Gender Identity?

  • Concept of gender identity underpins diagnosis of GD.
  • No universal agreement as to its meaning/aetiology/course of development.

What is Gender Identity (GI)?

  • Numerous clinical reports of successful gender changes occurring well after 2-3 years when gender role is supposed to have stabilized.
  • John Money claimed that gender was solidified by the age of 2-3 years.
  • Psychoanalyst Robert Stoller proposed concept of ‘gender identity’ to differentiate the psychological sense of self from the social role (in the 1960’s).

Gender Identity… origins in the 1960’s

  • Stoller, 1964, p. 453: “Almost everyone starts to develop from birth on a fundamental sense of belonging to one sex.
    The child’s awareness, “I am a male” or “I am a female” is visible to an observer in the first year of life. This aspect of one’s overall sense of identity can be conceptualized as a core gender identity produced by the infant-parents relationship, the child’s perception of its own genitalia, and a biological force which results from the biological variables of sex”.
  • John Money integrated the term ‘gender identity’ into his own theory, but without the psychoanalytic interpretation.
  • For Money, the term gender identity came to describe the inner psychological experience of the individual while gender role was maintained for its public expression.

Gender Identity…more recently!

  • Yogyakarta Principles, 2006:
    • … each person’s deeply felt internal and individual experience of gender, which may or may not correspond with the sex assigned at birth, including the personal sense of the body (which may involve, if freely chosen, modification of bodily appearance or function by medical, surgical or other means) and other expressions of gender, including dress, speech and mannerisms.
  • ‘Gender identity’ used alongside the ‘born in the wrong body’ in everyday language.
  • Critiques:
    • A subjective claim which, without objective external referents, is unverifiable and reinforces gender stereotypes of masculinity and femininity (Brunskell-Evans, 2019).
    • No scientific evidence for different brain and body sex in transgender individuals.
    • ‘Gender identity’ tends to privilege notions of a clear, coherent and unitary identity over conceptions of blurred identifications (Waites et al, 2009, p 147).

Significance of Contested Meanings

  • Meanings and theories regarding concept of gender identity are contested.
  • This contest is being played out socially, culturally and politically.
  • When Gender identity stabilises is important for medical management of gender transition as some of treatments have irreversible effects.

Medical Treatment for GD in Adolescence

  • Understanding of biomedical effects of treatment critical for ethical analysis.

Georgie Stone (Recap)

  • Diagnosed with Gender Dysphoria age 7, Puberty started at 10.
  • Youngest individual to be prescribed PBs & CSH for GD.
  • Socially transitioned in primary school.
  • Medical Treatment:
    • Stage 1: Puberty Blocking Treatment. Georgie started at age 11.
    • Stage 2: Cross-sex hormones. Georgie started oestrogen at age 15.
    • Stage 3: Surgery (age 19).

GD Treatment Model

  • Aim to relieve severe dysphoria and facilitate exploration of gender identity.
  • Affirmative model of care – gender identity supported & affirmed, (not challenged).
  • Underpinned by psychological support for individuals and families.
  • Assistance regarding social transitioning – living according to gender identity expressed.
  • Individuals may suffer range of co-existing mental health issues, require Dx & Rx.
  • Treatment individualized.
  • Three stages medical treatment for gender transition.

3 Stages of Gender Transition for GD

  • Stage 1: Puberty blockers for adolescents with GD who have attained Stage 2 Tanner development of puberty.
    • Average age about 12.
  • Stage 2: Cross sex hormones to masculinize or feminize the body. Age 16.
  • Stage 3: Gender affirming surgery. Change primary and/or secondary sex characteristics.
    • 18 years and over.

Normal Puberty

  • Puberty starts average age 10 in girls, 12 in boys, takes 5-6 years to complete.
  • Hypothalamic-pituitary-gonadal (HPG) axis, largely dormant in childhood; activated at puberty.
  • Reproductive organs enlarge substantially.
    • The size of the testes increases approximately 8-fold, while penile length and diameter double from Stage 1 to full maturity.
    • The uterus is a grape-sized organ (3−4cm33-4 cm^3) in pre-pubertal girls but grows to the equivalent of a large pear (120cm3120 cm^3) by sexual maturity.
  • Development of secondary sex characteristics.
  • Gonadal steroids also promote bone growth.
  • By age 16 years in girls, and 18 years in boys, a distinctly adult body shape has developed.

Stage 1: Puberty-Blockers (PBs)

  • A transitional strategy prior to making a permanent commitment to gender reassignment.
  • Rationale:
    • PBs gives adolescents time to explore their gender identity without the unwanted pubertal development of the sexed body.
    • This will ease psychological suffering.
  • Effects of PBs are reversible and if stopped allow natal pubertal development to resume.
  • PBs will also improve the outcomes of future hormonal therapy and sex reassignment surgery by increasing the ability to socially pass compared to post pubertal transition.

How do Puberty-Blockers (GnRHa) work?

  • GnRH agonist-initial surge followed by down-regulation of receptors on pituitary gland.
  • This results in desensitization of pituitary to continued stimulation by GnRHa.

Effects of PBs in Young Adolescents

  • Development arrested at Tanner Stage 2.
  • Individuals will demonstrate sexual and physical immaturity, compared to their peers.
    • Biological girls stops breast development, uterus growth and menstruation, and female patterned hair development.
    • Biological boys stops penile and testicular growth, male patterned hair development, voice box enlargement.
  • Reproductive function will also be completely undeveloped.
  • Body growth will still occur, although the accelerated growth spurt induced by gonadal steroids will not take place.
    • Adolescents will therefore tend to remain smaller than their peers.
    • They will eventually catch up to normal adult height because their bone growth plates will remain unfused until a later age.

PBs: Reversibility

  • Stop PBs – restart puberty at Tanner 2 and takes time to reach maturity of the sexed body
  • Fertility restored once pubertal changes completed unless cross-sex hormones commenced.
  • However, the vast majority of children on PBs don’t stop them but continue on to cross sex hormones ‘ of the adolescents who started puberty suppression, only 1.9 per cent stopped the treatment and did not proceed to CSH’ (de Vries cited in Bell v Tavistock [2020] EWHC 3274 [Admin]).

Disputes About Gender Identity

  • Gender identity contested.
  • Differences in perspectives play out when it comes to explaining why nearly all adolescents with GD continue on PBs.
  • Different Interpretations:
    1. PBs give adolescents time to confirm their gender identity and decide on gender transition.
    2. PBs restricts adolescent exploration of gender by halting sexual development.

Stage 2: Gender Transition - Cross Sex Hormones (CSH)

  • Decrease dysphoria.
  • Produce feminisation or masculinisation.
  • Side effects (oestrogen-thromboembolism & liver dysfunction; testosterone-increased risk cardiovascular disease).
  • Infertility: Oestrogen in biological male suppresses spermatogenesis and leads to degeneration of the testicular tissue.
  • Testosterone in biological female suppresses ovulation and alters the cellular makeup of the ovaries.

Georgie and Her Activism (Recap)

  • Georgie had to apply to the Australian Courts to access to Puberty blockers (age 11) and Cross Sex Hormones (age 15).
  • She advocated for legal change removing barriers to access gender transition treatment for adolescents.
  • Georgie now a successful Australian actor and writer and continues to advocate on behalf of transgender youth.

Change in Australian Law

  • As of 2017, Court approval no longer required for PBs or CSH for adolescents under the age of 16.
  • The importance of the consensus of expert opinion in informing the Court’s ruling was acknowledged:
    • ‘Justice Thackray held that the judicial understanding of gender dysphoria and its treatment had fallen behind the advances in medical science…’

Case History 2: Keira Bell

  • Keira Bell is a young activist who challenged the law in the UK.

Keira Bell's Experience

  • Born a girl.
  • At age 14 experienced discomfort with her body.
  • Didn’t identify with femininity and hated the idea of growing into a woman.
  • Became attracted to girls and wondered if there was something inherently wrong with her.

Keira's Transition

  • At 16, diagnosed with GD and started Stage 1 PBs
  • At 17, started Stage 2 testosterone treatment
  • At 20, Stage 3 surgical treatment with bilateral mastectomy

Detransition and Regrets

  • Soon after surgery, Keira started to have doubts about her transition.
  • Ceased testosterone and resumed living as a female. Initiated a legal case against the Tavistock clinic arguing she was too young and lacked the capacity to provide informed consent for GD treatment.

Keira Bell's Statement

  • Felt her decision as a teenager negatively affected her life.
  • Expressed concerns about the irreversible physical, mental, and legal changes.
  • Transition was a temporary, superficial fix for a complex identity issue.

Affirmation Model Critique

  • Keira Bell argues against the affirmation model, which she says sets young people on a path towards puberty blockers and cross-sex hormones.

High Court of Justice Judgment - 2020

  • The judgment rejected the notion that children under the age of 16 are likely to achieve Gillick competency in this situation.
  • The judgment stated that patients were effectively consenting to both PBT and cross-sex hormones, and that the consequences of this treatment regime are potentially lifelong and life changing.
  • There will be enormous difficulties in a child under 16 understanding and weighing up information and deciding whether to consent to the use of puberty blocking medication.

Judgment Claims

  • Lack of medical consensus.
  • There is real uncertainty over the short and long-term consequences of the treatment with very limited evidence as to its efficacy.
  • This means it is properly described as experimental treatment.
  • The High Court reviewed medical evidence provided by medical experts representing the claimant and the defendant, including expert perspectives which are at odds with those of WPATH and the Endocrine Society.

Appeal

  • September 2021 An Appeal of the Bell v Tavistock decision was successful.
  • Appeal upheld Gillick competency, and the court judges stressed that “it was for clinicians rather than the court to decide on competence (to consent)”.

Cass Report

  • Review of GD services for young people by the NHS England.
  • Lack of evidence base for Puberty Blockers.
  • WPATH guidelines “lack developmental rigour & transparency”

CASS Recommendations

  • NHS with gender dysphoria no longer receive puberty blockers as routine practice.
  • The use of puberty blockers restricted to participation in clinical trials as more research needed.

Is There a Consensus?

  • Medical expert consensus regarding the treatment of young adolescents with GD is based on the World Professional Association for Transgender Health (WPATH) and the Endocrine Society guidelines.

Endocrine Society Recommendations (2017)

  • We suggest that adolescents diagnosed with GD should initially undergo treatment to suppress pubertal hormones when boys and girls first exhibit physical changes of puberty
  • In adolescents who request sex hormone treatment we recommend initiating treatment in adolescents who have sufficient capacity to consent.
  • Update 2025: metanalysis by Miroshnychenko et al conclude evidence base Very low.

Evidence Based Medicine: Grade System

  • High: We are very confident that the true effect lies close to that of the estimate of the effect.
  • Moderate: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
  • Low: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
  • Very low: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

Insufficient Evidence?

  • Pilgrim and Entwistle, (2020) argue that PBs lacks a robust evidence base for benefits and efficacy (in relieving dysphoria).
  • There is concern amongst many mental health professionals about the treatment but saying so publicly is difficult because it is such a heated issue (Evans, 2020).
  • Counter arguments:
    • High quality evidence from RCT’s not possible in this area.
    • This treatment regime now over 2 decades with accumulating body of research
    • There is expert consensus by clinicians who care for this cohort based on this research (Endocrine society guidelines and WPATH).

Change in the UK and Elsewhere

  • Denmark, Sweden, Finland, and Norway significantly restricting hormone Rx to youth.
  • Italy now recommends psychotherapy as the first line of treatment and limits puberty blockers to controlled clinical trials.

Australia

  • 2025: Queensland instigated review re the evidence base for use of puberty blockers in GD for young people – currently underway.
  • Meantime – immediate pause on hormone Rx for young people under age 18.
  • Australian Government announced (another) review, by NHMRC on standards of care for transgender youth. No ban on hormone Rx in other Australian states whilst awaiting report due 2026.

USA

  • Funding restricted for hormone Rx for transgender youth including puberty blockers.
  • Currently 23 of the States have legislated to restrict gender affirming care mode and move towards a more watchful, non-interventionalist model.
  • No longer a consensus in favour of gender affirming care.

Where to Now?

  • Lack of consensus.
  • Debate : Evidence Based Medicine for management regime. Capacity to consent.
  • The key points of Priest article to which the 2 tutorial papers (Laidlaw et al and Clarke et al) are responding.

Maura Priest: The Right to Transition

  • Transgender Children and the Right to Transition: Medical Ethics When Parents Mean Well but Cause Harm
  • Transgender adolescents should have the legal right to access puberty-blocking treatment without parental approval.
  • Not all children will meet Gillick competency, however they should still get access to gender transition Rx for the same reasons that children are removed from their home if neglected or blood transfusions are allowed for children of Jehovah’s witness.
  • Serious risk of not treating (psychological harm, physical harm – abuse, self-medication, suicide).
  • Child’s right to their body

Next Ethics Tutorial

  • Read articles by Laidlaw et al. (against) and Clark et al. (in support).
  • Critically evaluate the papers and formulate questions before deciding on the ethics of puberty blocker use for young adolescents with Gender Dysphoria.
  • Address the question: “Is it ethical to prescribe puberty – blockers to young adolescents (under the age of 16) who are diagnosed with Gender Dysphoria?”