Drugs for trans kids a health risk, say doctors

Doctors at a hospital home to Australia’s biggest youth gender clinic have sounded the alarm about ‘puberty blocker’ drugs.

Family at Pride Parade. Picture: iStock

 

EDITORIAL: We will not shy away from uncomfortable topics that deserve attention. This is particularly so when the health and wellbeing of vulnerable children are at stake.

Doctors at a hospital home to Australia’s biggest youth gender clinic have sounded the alarm about “puberty blocker” drugs given to transgender-identifying children as young as 10.

In reply to a BBC analysis of the puberty blocker controversy in the British Medical Journal, four doctors from the Royal Children’s Hospital in Melbourne have called for “greater vigilance” about trans youth patients losing bone density, with lifelong implications such as osteoporosis.

There is growing international disquiet about puberty blockers, which have been promoted by gender clinics as safe, reversible and simply “a breathing space” while kids work out gender identity. Blockers are the first step on the “gender change” path to cross-sex hormones and sometimes surgery to relieve “gender dysphoria” or severe distress about one’s biological sex.

In their BMJ letter, the RCH doctors argue that bone density in trans youth has not been measured properly, and it will be “difficult to optimise (their) bone health” without first teasing out several risk factors, including when puberty blocking starts and ends, exercise and body type.

They call for international research on risk factors and remind clinicians of their “duty of care” to look after the bone health of these young patients.

RCH gender clinic director and paediatrician Michelle Telfer, whose name is not on the letter, has promoted earlier, faster and cheaper access to puberty blockers, while warning against prolonged treatment.

The BMJ letter is signed by two endocrinologists — experts in hormones — while the contentious 2018 RCH treatment standards for trans youth have no endocrinologists among the credited authors. The only overlap is gender clinic research doctor Ken Pang, whose name is on both documents. The Endocrine Society of Australia and the Australasian Paediatric Endocrine Group said they were not consulted during development of the RCH standards. RCH did not reply to ­requests for comment.

‘Experimental medicine’

Dr Telfer has claimed puberty blockers “don’t stop growth generally, or your brain from maturing emotionally and cognitively, they just stop the sexual characteristics from developing”, although her clinic’s 2018 treatment standards acknowledge the bone density risk and the fact that the long-term effect of blockers is “currently unknown.”

She argues trans medical treatment “improves mental health outcomes, reduces anxiety, reduces depression and decreases the suicide risk significantly.”

American endocrinologist Will Malone, lead signatory on the latest appeal to Mr Hunt, said the BMJ statement from the four RCH doctors seemed to acknowledge that giving puberty blockers to trans youth was “experimental medicine.”

“This is an astonishing admission, given the (2018 RCH treatment) transgender guidelines so aggressively promote social, medical and surgical affirmation,” he told The Australian.

“No one knows what the long term effects of these interventions will be, not only on bone density, but on brain development, cardiovascular risk, cancer risk, and suicide risk.”

The RCH treatment guidelines say bone density is “the main concern” with puberty blockers, advises “regular monitoring” and encouraging teens to get enough calcium in their diet and to do “weight-bearing exercise.”

Western Sydney University professor of paediatrics John Whitehall, a critic of the affirmation model, said he was less worried about bone density than brain development.

He cites studies in Scotland and Norway that found sheep given blocker drugs suffered damage to the limbic system of the brain, which is involved in “executive function” or cognitive control of behaviour.

As part of a long-term study launched in 2017, the RCH clinic has advertised a PhD project with the pitch that puberty blocking typically lasts “several years, and provides an opportunity to learn how the teenage brain develops in the absence of sex hormones.”

US support

Meanwhile, a group of eight US clinicians has written to Health Minister Greg Hunt supporting the local call for a parliamentary inquiry into the safety and ethics of medicalising trans-identifying children and adolescents. They challenge as “unproven” the refrain of the pro-trans “affirmation” clinicians that treatment risks are outweighed by the mental health benefit to suicide-prone youth diagnosed with gender dysphoria.

In their letter they say puberty blockers have been “misrepresented as a safe ‘pause button’, (but) emerging evidence shows that they have profoundly negative effects on bone and brain health.

“Nearly 100 per cent of patients go on to cross sex hormones after starting puberty blockers, whereas historically 85 per cent of dysphoric children who were allowed to go through natural puberty had remission of their distress without the need for medical interventions, with the majority growing up to be lesbian, gay, or bisexual adults.”

The US group cites early data from London’s Tavistock youth gender clinic of a possible increase in suicide risk in patients after a year on puberty blockers, although it was hard to know what to make of this because the Tavistock study lacked a non-treatment control group.

A UK health regulator’s report into that study last week implied gender clinics should no longer pitch puberty blockers as “a breathing space” because in practice they are followed by irreversible cross-sex hormones which can leave them infertile and permanently dependent on doctors.

Earlier this year, UK paediatrician Christopher Richards and three other practitioners warned in the journal Archives of Disease in Children that halting “the natural process of puberty is an intervention of momentous proportions with lifelong medical, psychological and emotional implications.

“This practice should be curtailed until we are able to apply the same scientific rigour that is demanded of other medical interventions.”

The Tavistock clinic faces possible legal action from the mother of a 15-year-old autistic girl who says her daughter cannot give informed consent to puberty blocker drugs with unknown long-term risks.

Debate unmuzzled

The UK-based Australian writer and lawyer, Helen Dale, predicts that if the case gets to court it will raise questions awkward for trans activists.

“Attempts to prevent public debate by making ‘transphobia’ claims — an effective strategy when directed solely at social media companies — will fail,” she writes in CapX magazine.

Dale lists questions likely to come before the court: “How likely is gender dysphoria to be misdiagnosed? What is the significance of comorbidities like autism or anorexia?

“Do patients — both children (judged competent to consent) and adults — understand that puberty blockers and, later, surgery, are major treatments with lifelong effects that can go badly wrong?

“Are there alternatives that involve less dramatic medical intervention?

“Is suicide statistically likely let alone inevitable if children’s gender identities are not affirmed?

“Experts will be called, including experts trans activists despise.

“The case will be widely reported and discussed across the press and on the BBC. Evidence from endocrinologists and biochemists drawing on what happened to East German athletes historically (who were often given testosterone as children) will be ventilated.”

‘Maximalist’ treatment

Meanwhile in the US, an Oregon-based paediatrician Julia Mason plans to challenge the American Academy of Paediatrics over the pro-affirmation treatment statement released last year to its 65,000-plus membership.

Dr Mason, a paediatrician for more than 20 years, said she was “shocked and dismayed” when she saw the statement, which she said “makes a lot of claims that aren’t even supported by the references that they list.”

She said she would go to the academy’s national meeting in New Orleans starting on October 25 to try to “buttonhole” doctors who developed the statement.

“The thing that really threw me was when I found out that the puberty blockers lead to continued medicalisation almost 100 per cent of the time,” she said.

Although the academy favours the model in which puberty blockers are followed by cross-sex hormones, Dr Mason said she was “super sceptical that 99 per cent of 11, 12, 13 year-olds know for sure what they want for the rest of their lives.

“The mind boggles. We don’t let kids get tattoos until 18 because we’re worried they might regret what seemed like a good idea.”

Earlier this month Dr Mason, a signatory to the Hunt letter, wrote for the popular physicians’ blog KevinMD.com about her concerns after seeing young trans-identifying patients in private practice.

“I’ve learned that if I refer a patient to the gender clinic, they are going to get the maximalist treatment,” she writes.

“They’re not going to get any help figuring out if they really need the full medical/surgical transition. I am now wary of referring to the gender clinic.”

She said she believed “a small number of non-medical activists have been able to capture academics, who then went on to influence the (treatment) guidelines and the recommendations” of medical bodies.”

A world authority on gender dysphoria, Canadian psychologist Ken Zucker, criticised the academy’s statement for its dismissal of the more cautious treatment approach of “watchful waiting.”

The AAP document claims this is an “outdated approach (which) does not serve the child because critical support is withheld.

“Watchful waiting is based on binary notions of gender in which gender diversity and fluidity is pathologised.”

Dr Zucker said: “I thought the document was so flawed it would require hours upon hours to refute the many parts of it — it was a dreadful piece of work.

“When I’m in a cynical mode I sometimes joke around and say, ‘if you don’t do research, you write guidelines’.”