The overriding issue dramatised in the second episode of ITV’s ‘Butterfly’ was a parent’s quest for puberty blockers in the face of a clinician’s caution. In this post, Susan Matthews looks at the case for blockers and examines the evidence for their use in treating gender dysphoric children.
“They Look Normal”
by Susan Matthews
In the first episode of Butterfly, we saw Max’s desperate parents repeat what they knew about the likely outcome of Max’s gender dysphoria. The dad knows it’s unlikely that the gender dysphoria will persist past puberty – he’s discovered online that
‘Apparently only a quarter of the kids, who, how do you call it, say, express themselves like that, you know, feel like that when they reach puberty. That’s what it says online, anyway. A lot of them just pack it in.’
The second episode is devoted to the mother’s increasingly desperate search for physical intervention, a search that will culminate in parental abduction as she tries to take the child out of the country against his father’s wishes. This frantic quest derives from the advice of the doctor in the first episode. If Max becomes more distressed, she tells them, he may need ‘puberty blockers to delay his development as a young man.’
GnRH agonists, or puberty blockers, are often presented as a risk-free intervention that is ‘fully reversible’: if the child does not want to proceed with transition they can be stopped, it is claimed, and puberty will restart, albeit at a later stage. The Dutch team who pioneered this intervention viewed this extra time as
‘an extended diagnostic phase, in which the distress the physical feminisation or masculinisation was producing is significantly reduced.’
If the child does want to proceed, blockers mean that the secondary sex characteristics triggered by puberty (broken voice, an Adam’s apple, facial hair in the case of boys, breast development in the case of girls) have been prevented and fewer surgical interventions will be necessary. If Max transitions, as an adult he will pass cosmetically as female and will not look trans. It’s a win-win intervention. Or so the argument used to go.
But there’s a case against puberty blockers that is becoming more compelling as some of the many gaps in our knowledge begin to be filled. We know that blockers vastly increase the likelihood that the child will remain on a medical pathway. In real life, it is the ‘online’ wisdom about desistance that is correct: ‘children’s GD/GV persists after puberty in only 10-30 percent of all cases’. As the GIDS team reported in 2016, these figures change if we provide puberty blockers:
‘Persistence was strongly correlated with the commencement of physical interventions such as the hypothalamic blocker (t=.395, p=.007) and no patient within the sample desisted after having started on the hypothalamic blocker.’
In this report, every one of the patients on the blocker persisted while 90.3% of those not on the blocker desisted. Either clinicians have semi divine powers of insight or the blocker itself strongly affected the outcome for the child. This drug is not the neutral reversible intervention that was claimed because
‘it freezes youngsters in a prolonged childhood, secluding them from certain aspects of reality and isolating them from peer groups.’
And even if Max does go on to transition, as Jazz Jennings discovered, puberty blockers will make a vaginoplasty more difficult because the surgeon has only a child’s prepubertal genitals to refashion into a simulacrum of an adult vagina: ‘genital underdevelopment may limit some potential reconstructive options.’ (It’s also much harder to remove a vagina on a natal female who has been puberty blocked because the skin deprived of oestrogen does not respond well to surgical intervention.)
A child whose puberty is blocked and who goes on to transition will necessarily be infertile. Currently there are attempts to offer ‘fertility preservation’ but a prepubertal child may not be able to ejaculate. Semen must be harvested via electro ejaculation under anaesthesia, the quality of the semen is likely to be low and the eventual use of the semen may require the use of a surrogate (a rented female body who will incubate the child of a surgically fashioned woman).
We know very little about the capacity for sexual pleasure in a natal male who proceeds to genital reconstruction after puberty blockade. But we know for certain that blockers reduce libido: they are after all also used to chemically castrate sex offenders. The medical treatment for sex offenders available on the NHS includes GnRH agonists used as ‘antilibidinal medication’. ‘Antilibidinal medication is associated with a range of side effects’ the guidance for clinicians warns, ‘including the risk of liver damage, breast growth, hot flushes, depression and a decrease in bone density.’ Puberty blockers put a natal female into a ‘pseudomenopause’.
This medication is a massive disruption in a child’s body. If Max does transition, (and offering puberty blockers will make that outcome virtually certain), blockers will improve appearance but destroy sexual function and fertility. On balance we might reasonably decide that letting the child go through their natal puberty whatever path they choose later on is the better option.
That’s how the choice might look if you were a clinician trying to weigh the ethical choices of beneficence (doing good) and non-maleficence (do no harm). But let’s suppose now that you’re the parent. You care desperately about your child and know their unhappiness. If you have not read some of the fact checking posts available on Transgender Trend or 4thwavenow you may believe that the choices are transition or suicide. Maybe also (and this is a difficult one for you to admit) you feel some revulsion at the idea that your child may not pass as an adult, may look ‘trans’.
Puberty blockers produce adults who pass: ‘They look beautiful, they look normal’, says Norman Spack, the doctor who treated Jackie Green and introduced the Dutch puberty blocker protocol to the US in 2007. Their future sex life is not something you really want to think about (they’re a child after all) and fertility seems far less important than simply keeping them alive. The 80% chance of desistance, you’ve heard, is a totally discredited figure (spoiler: it isn’t).
Faced with this difficult choice any parent might question the advice of the GIDS team. But if it was my child I would do some research. I would check every footnote and ask who benefited from every intervention on offer. I would reject simple or emotive answers and would have no patience with euphemism or bland reassurance. I would think hard because the future happiness of my child was in my hands.
And as I did so, I would become increasingly concerned about the experimental nature of the puberty blocker protocol and the quality of the evidence on which it is based. A review published in 2018 mentions ‘Low-quality evidence’ and ‘knowledge gaps’.
I would worry that puberty blockers have been used on human subjects before any animal studies (normally it is the other way round). And I would not like the fact that sheep whose puberty is temporarily blocked with these drugs have lasting mental effects: ‘How worried should we be by these findings when we prescribe puberty blockers?’ asked a gender clinician on hearing these findings last week at a conference at the Tavistock clinic. To which the researcher could only answer: ‘That’s a question for clinicians.’ Because GnRHa treatment produces ‘a drop of around 8 points’ in IQ, its value even as a treatment for precocious puberty in children is now being questioned.
I would find out that in MtF patients the loss of bone strength caused by puberty blockade is not fully compensated by later cross sex hormones. I would be concerned that the 22 year follow up on the first puberty blocked kid (who was FTM) reveals a handsome, professionally successful man who has been hindered from maintaining an intimate sexual relationship by shame at their constructed genitalia:
‘B considered it likely that his need to distance himself from her had been related to his shame about his genital appearance and his feelings of inadequacy in sexual matters.’
I would want to know why a drug company, Ferring, sponsored the crucial Dutch trial into puberty blockers: the 2006 Delemarre-van de Waal and Cohen-Kettenis paper was ‘presented at the 4th Ferring Pharmaceuticals International Paediatric Endocrinology Symposium, Paris (2006)’ and Ferring Pharmaceuticals supported the publication of these proceedings.’
Ferring was interested in this novel use for their expensive drug because they market Triptorelin, one of the GnRH antagonists used in gender clinics under the brand names Diphereline and Gonapeptyl.
The Amsterdam clinic was financially supported in its experimental project to block puberty in gender dysphoric adolescents by a pharmaceutical company which stood to make commercial gains from their new protocol.
I would not want my kid’s choice to be driven by the profit motive of international drug companies or the curiosity of endocrinologists.
The duty of a parent is to seek out the truth and to offer that truth, however difficult, with kindness to a child. I remember the moment my toddler son asked me ‘Will I die?’ (he wasn’t ill, it was the moment it struck him that he was mortal). I wanted to tell him he was immortal – but I didn’t. And when your child asks ‘But how does the sperm get from the man into the woman?’ you have to take a deep breath and explain. (‘That’s amazing! We must talk about it more tomorrow’, he said, and never mentioned the topic again.) Children ask us about bodies, and sex and death because they do not come into the world knowing these facts. I believe that being kind rather than truthful ultimately stores up problems for children. Sometimes, it is our own feelings that we are trying to avoid rather than the temporary, but intense, distress of our child.
Children do not have a ‘self’ that can be uploaded onto the iCloud for downloading into a different body later on. The changing brain, moulded by surges of hormones, by thoughts and feelings and behaviour, creates a new self that we cannot envisage – no parent can predict how their child will change at puberty. The ‘most dramatic change during those years happens to the prefrontal cortex, the area of the brain involved in high level cognitive functions such as decision-making, planning, social interaction and self-awareness. MRI studies show that this region undergoes quite dramatic change during adolescence.’ If puberty-blocked sheep take more risks does that explain why adolescents on puberty blockers will risk their future sex lives?
When we block the surge of hormones that create the adolescent brain we invent a new kind of human being: cosmetically perfect but lacking sexual and reproductive function. When a puberty-blocked Jazz Jennings asks her parents whether an orgasm is like sneezing and interrogates her father about how much of her mother’s vaginal canal he can see, we know that Jazz is not an adolescent. Jazz can only imagine being the object of the male gaze. She plans to provide a sexual service because she has no access to sexual feelings of her own. This isn’t a new openness about sex but a young person who has not separated from their parents. When we offer our kids the same medicines which are used to chemically castrate sex offenders something has gone badly wrong.