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You're listening to transm on 4zzz, amplifying the trans and gender non conforming voices of Brisbane and beyond.

Good morning, Meanjin. You're listening to Transmission on 4zzz. Transmission. All about amplifying the voices of the trans community and beyond. My name is ez. I use he, him pronouns.

My name is Bet. I use she, they pronouns.

Hello, Bet. How are you this morning?

Oh, I'm good overall, but a little tired because I was up late doing my research last night.

No, you're getting prepared.

Yes, I'm always prepared when I come in here.

I do like that about you.

Yeah, I just. I want to make it. Make it count. Make every minute count.

All right, well, let's not waste any seconds. What are we talking about today?

We're gonna talk about puberty blockers. As I said to you the other day, I was thinking of doing like an advocacy toolkit, especially for parents, perhaps because I've had a couple of parents ask about that sort of thing. But I realised what a huge job that is and actually I'm probably gonna do it series of posts online or something like that. So I focused on puberty blockers.

All right.

Puberty blockers, as you just said, I don't think any of us. Well, maybe not any of us, but a lot of us don't know all that much about puberty blockers. Right. Like I didn't for a very long time.

Yeah. And as a trans masc person, puberty blockers who transitioned much later in life. Yeah, definitely not something I've had to look at.

Not relevant to me personally either. But you know, I've been advocating for them for a long time, so I figured I should do a deep dive. I was pretty confident that they were the right thing to do in some circumstances. Most circumstances perhaps.

Yeah.

But now I'm very, very confident. Woo.

Let's do it.

Okay, so quickly. Puberty blockers is a colloquial term. What we're talking about is gonadotropin releasing hormone agonists. Gnrha.

Damn.

So what they are is a biosynthetic or an analogue version of gonadotropin releasing hormones which are the hormones responsible for initiating puberty. And they occur naturally in the body. So they're not actually blocking anything. What they're doing is that instead of the young person getting these hormones in pulses, they get them at a steady level. And that means that the receptors get down regulated and the brain never sends a signal to the gonads to make sex steroids.

Right. Okay, so it's cutting off a signal before it goes anywhere sort of thing.

Yeah, Right. By using a hormone that's already present in the body, basically, or a synthetic version of it. So briefly, the Australian Standards of Care by Michelle Telfer et al. Says that puberty suppression typically relieves distress for trans adolescents by halting progression of physical changes such as breast growth in trans males and voice deepening in trans females. And it is reversible in its effects. The adolescent is given time to develop emotionally and cognitively prior to making decisions on gender affirming hormone use, which may have some irreversible effects. So I just want to push back on that a little bit. I feel like the time to think argument, the argument about the adolescent being given time to develop emotionally and cognitively is. I don't know, I've come to question the validity of that argument. I have no doubt there are some cases in which adolescents may want time to think, but I think, well, especially if they're non binary. But I think that most trans young people that start on puberty blockers are probably pretty clear about where they're going, would you agree? Like they're headed for HRT in most cases.

In most cases. I think also a lot of people on puberty blockers are buying time. Right. As well.

Now, I was going to come around to this later, but one thing I wanted to say on that was that the cast review has weaponized the time to think argument and the buying time argument by pointing out that 98% of adolescents who went through the Gender Identity Development Service and this was a lot of adolescents, like 7,000 or something.

Wow.

98% of them went on to HRT.

Wow, that's pretty high.

It's very high. And that statistic is pretty much the same in every study that I've seen. Varies a tiny bit, but it's always over 95% from what I've seen.

That's incredible.

And anti trans journalist Hannah Barnes wrote her book about jids. She, she called it Time to Think and she was mocking, basically. I don't know if mocking is the right word, but she was trying to debunk that idea that we're giving kids time to think. And to be honest, I sometimes think what we're doing is we're giving society time to think. We're giving maybe parents and probably in some cases physicians because they want to be sure that they're doing the right thing. But in many case, I mean, I don't see the point in having a, maybe a child that's been gender dysphoric for a long time or has. Has known that they were gender incongruous for a long time, whether or not they're just, they're suffering, you know, several years, and then they get to maybe age 12, we put them on puberty blockers until 16. That doesn't make any sense to me.

Yeah, right.

But I'll get, I'll get back to that later and I'll just look at some other common claims made by our side first and then I'll look at some claims made by the other side. So one claim made by our side commonly is that puberty blockers reduce dysphoria. So researcher Cal Horton, and I've forgotten where Cal works, I use their references so much that I forgot to look them up. Cal Horton says puberty blockers are not expected to resolve gender dysphoria. They are not expected to lead to an improvement in mental health and well being. They are intended to present prevent the catastrophic decline in mental health and well being that is known to occur when trans youth are forced through a puberty they find intolerable.

Yeah, yeah.

And that's important because when we claim that blockers are a treatment for dysphoria, then folks like Hilary Cass come along with studies showing no statistically significant decline in dysphoria and we look delusional. The point isn't to reduce dysphoria. The point is to kind of stall it until the young person can get on hrt. That is what reduces dysphoria. The purpose of puberty blockers is one thing and one thing only, really, and that's to delay puberty. And they work perfectly for that. And the reason why we delay puberty is to avoid suffering. Not necessarily always to reduce suffering. I think that's an important point if we're going to be advocating for trans young people where there are increases in well being associated with blockers. Some physicians theorise that it may be because adolescents can see a clear route ahead to getting hrt, which is what they really want. I doubt that there are many adolescents who are excited at just being on puberty blockers. Like they'd be relieved, but it's not like they're going to see any positive changes from it. Right. They're just going to be stalled where they are. There was a study presented At WPATH in 2024, Chen et al. It's not yet published. It emphasised that for trans youth with family support, low levels of minority stress and good mental health from childhood puberty blocker treatment would not lead to an improvement in mental health, but a retention and a protection of the mental health they already have, the good mental health they already have. So that highlights that looking for mental health improvements is the wrong metric here. Similarly, for trans youth facing lack of support and higher rates of minority stress, gender affirmative health care is not expected to eradicate mental health challenges. So back to the Australian standards of care again. They say the main concern with use of puberty blocker puberty suppression from early puberty is the impact it has on bone mineral density. Reduction in the duration of use of puberty suppression by earlier commencement of stage two treatment must be considered in adolescents with reduced bone density to minimise negative effects. So, again, I guess I bring that up because it's another argument that maybe we should bring it HRT forward.

Yeah.

In some cases. And not have these young people on.

Like, stalled for such a long period.

Yeah. Physicians who work with trans youth, however, all agree that this does not seem to be a big issue. In most cases, they scan for bone density regularly. They recommend exercise and vitamin D supplements. However, I do wonder how many kids actually do that exercise. I know I probably wouldn't have as a.

And particularly if you. If it's not, you know, like, quote, unquote, fixing your dysphoria, it's stalling the development of something you don't want, you're still probably not necessarily going to feel super comfy in your body yet.

Exactly. I think in many cases that's true. Dr. Simona Giordano, she is a professor of bioethics at the University of Manchester. She testified before the UK's Women Inequalities Committee regarding the ban on puberty blockers. She says in the literature there is no reported case of complaint around loss of mineral density from the cohort of children treated since the mid-1990s. There is no report in the literature, no litigation, no complaint through clinical authorities from patients. Giordano also says, with reference to a claim made by the CASS review, which is really a claim that Segum made and put in the CAS review. I'm sure, Giordano says, in this cohort, in the persistent studies that have been conducted since at least 2016, it appears that those individuals who, after the onset of pubertal development would experience and continue to experience strong and persistent gender dysphoria will always, nearly always later become applicants for medical treatment for transition, regardless of whether or not they had been given puberty blockers. So the point there is that Cass makes this claim completely unfounded, that because of that 98% continuation onto HRT rate, Hillary Cass and Segum make the claim that it's puberty blockers that are trans in kids. That it's. So there's this saying, you might have seen it around if you, if like me, you ever look at anti trans websites? I think the slogan is puberty is the cure. So what they're saying is that, and they're citing these debunked desistance studies from the 70s and 80s, what they're saying is that if the child is able to have their endogenous puberty, that, that puberty will kind of cure them of the, the delusion that they are a different gender because they'll.

Oh yes, they'll just develop things they don't want and be fine with it.

Exactly, exactly. There's, of course, there's no evidence at all for that. And as Giordano says there, it appears that whether or not kids since 2016 were given blockers, if they were very dysphoric in 2016 or you know, when at the age where they would have been given blockers, then whether or not they had blockers, they still went on to be translated. Yeah, yeah, pretty obvious. But we have to spell these things out sometimes.

Peter Sterling, the only man in the world who's given birth to a child. Someone might say you're a bit of a queer. Then they'd be, Brian, you're listening to transmission on 4zzz. My name is Ez, I use he, him, pronouns.

My name is Bet, I use she, they pronouns.

And just a little shout out to Eliza in Clayfield. Thank you so much for subscribing to 4 triple Z, keeping transmission on air, keeping us all on air. Thank you so much.

Thank you.

Yeah.

Okay, let's dive back in. My next question, which in response to people like Hillary Cass, the Cass review, the Queensland government trying to ban puberty blockers is, are puberty blockers experimental treatment? This claim is often made by the other side. So off label use is the use of a drug for an indication that is different for the one for which it is licenced. This happens a lot in paediatrics because a lot of drugs have only been tested on adults and the licences are only for use in an adult population. But this usage is endorsed by peak bodies such as the Royal College of Paediatrics and Child Health in the uk. The term off label does not imply anything illegal, contraindicated or experimental. Researcher Giordano, who I mentioned earlier, says it is not primarily the lack of research that prevents the licencing of GnRH agonists for puberty delay in adolescents with gender dysphoria. It is likely that GNRH agonists could be licenced based on already existing research. But no one has an incentive to use the necessary resources resources to submit a licence application. And that's because they've been being used since 1988 for this purpose, I think. 88. I may be wrong about that. But the 80s anyway. And they're widely thought to be safe by everyone who uses them. So there is no incentive for drug companies to go through the fairly arduous process of applying to have them on label. Another thing that Hilary Cass and people who campaign against puberty blockers often say is that we need randomised controlled trials. I won't dwell on this too much because I think that everyone in the trans community by now probably realises how ridiculous this is.

Yeah.

But I will spell it out for those who've just tuned into the argument briefly. Blinding is necessary in a random controlled trial to reduce bias. But you can't blind a random controlled trial of puberty blockers because it would very soon be obvious to both participants and researchers who was on the blockers and who was not. That would also mean that participants who were denied blockers would be likely to either withdraw from the study and high dropout rates are another source of bias, or seek blockers outside of the trial.

Yeah.

But also it's unethical because can you imagine the sheer distress of those young people who've been waiting in many cases for a long time as they jump through all the hoops to get on puberty blockers.

Four, nine, one here.

Yeah, exactly. And then they finally get there and they're given a placebo and they realise that within three months. I think the distress could actually be fatal in some cases.

Yeah, definitely.

So Giordano points out that a RCT would not be an effective way to study long term negative side effects either. So things like bone density, if that is an issue, then it might not turn up until a lot later. And random controlled trials are not longitudinal studies. They don't generally last very long at all. Another accusation by the other side in this argument is that there's a lack of so called High quality studies. Now firstly, that is a specific scientific term used by the grade system, which is a system of rating studies that's used commonly in systematic reviews. So the CAS review was ostensibly based on, I think it was five systematic reviews done by the University of York in England. There are some problems with those systematic reviews, although on the whole I think the consensus is that they're convincingly done. There are a few strange quirks about them that show a potential bias. But there's a question about whether the grade system is. And it wasn't even the grade system that was used, it was a modified version of the grade system. But there is a question about whether that was the right way to grade studies in this field. Because things that can make a study, quote unquote low quality in that system are things like tiny cohort sizes. But there just aren't that many young people that go on puberty blockers. So it's very hard to have a study that has a large cohort size. There's often only one gender clinic in any given country. For instance in Holland where gender affirming care for young people was pioneered and where puberty blockers were first used for this purpose. So the studies that were done there in the late 80s and early 90s and were actually into the 2000s, there was only one gender clinic in the country so they couldn't spread the study over different sites science, which is another way that you have a so called high, high quality study. And lastly, there's just very little funding for trans related research. So again it's very hard to set up these big studies because that they require money spending.

Yeah, unfortunately yes.

So as Cal Horton says, should we review all the literature to see what benefits and harms can be found and make the best possible decisions based on existing evidence whilst highlighting future research priorities? Or should we critique the quality of existing literature, rule it of insufficient quality, rule it therefore inconsequential and then proceed to policy making with no consideration of the existing evidence base. I think it's pretty clear we should probably, probably do the first.

Yeah, yeah, yeah.

So earlier I said I'd return to the time to think argument. So I found a video by someone called Johanna Olson Kennedy who I'd never heard of before, but she's a bit controversial at the moment. She's a specialist in trans care working in Seattle, Washington. I think she did the speech in Seattle. Anyway, she's currently being taken to court by a so called detransitioner, someone who returned to identification with their gender assigned at birth. And she has this to. Well, actually she also was the topic of a New York Times article which Erin Reid writes about. I'll put that link down below. The New York Times made out that she had suppressed research. That. That's not actually true from what I can see. So anyway, Johanna Olson Kennedy says this is interesting, I didn't know this, that pubertal timelines are different in ovarian and testicular puberty. So for transmasculine kids, she says that we're Talking about age 9, 10, 11 when puberty starts. This is later for trans femmes. So preventing puberty if it's going to happen, and it rarely does apparently for transmasculine kids because they just don't get in there that early.

Yep.

Preventing puberty is needed earlier for transmasculine kids. So what she says is that a lot of 13 and 14 year old transmasculine kids come into the service, they're already through puberty because they started it at 10, but they have to go on puberty blockers because that's the law, because they can't go on to hrt until they're 16. And in many constituencies you actually have to have been on puberty blockers for some time before you can actually access hrt, whether or not they're doing anything worthwhile for you or not. So in this case, when a trans mass kid goes in at age 14, they've already gone through puberty, but they have to wait till 16 to get on HRT. They go into menopause when they go on puberty blockers. Yes, because they have no sex hormones in their body. So they have hot flashes, they'll have insomnia, they'll have short term memory problems and they'll have an exacerbation of depression. And again, then this shows up in some studies. And then the other side weaponizes it, saying that, that it's the blockers that are having the negative effect, but actually it's the timing of the blockers that's having the negative effect. She says on the other hand, that trans feminine folks on. She talks about trans feminine folks on puberty blockers. Oh, hang on. By the way, I didn't write this down, but her solution to that is to give micro doses of tea to trans mass kids. And I'm not sure of the legality of that. But she says that's the only solution for putting them through menopause.

Yes. Well, you need to, you need to give them a hormone.

Yeah. So they end up again stalled for two Years for no particular.

They need it, it needs, they need to have a sex hormone at that point. Yeah, essentially.

Yeah, exactly. So meanwhile, for trans femmes, she says that she feels like in some ways they're suspending those kids. In the worst part of female puberty, she says, it's like we're saying, hey, sit here, none of your friends will be here, but here you go, and it's really hard on them and the dosing can be problematic. And this is a common observation about trans adolescents being stuck on puberty blockers, that it can be alienating. So Stephen Rosenthal, San Francisco specialist in care of trans youths, mentions the potential negative effect on bone health of extended puberty blocker use and argues for an earlier introduction of horizontal. But he also notes the negative impacts on emotional well being when you deny trans youth the opportunity to progress through puberty at the same rate as their peers, thereby socially isolating them. Now, I've hesitated to say this stuff in public for quite a while because I didn't really want to go against the prevailing narrative. And so often the narrative is, oh well, puberty blockers buy kids time to think and, and it's important and blah, blah, blah. But I've just really come to, I.

Wonder if it's, you know, yeah, like you said, it's not buying time for young people to think. It's buying time for society to find a reason to deem it unacceptable or acceptable.

Exactly. It's because society, society is squeamish about the idea of a young person going on HRT at a young age in some cases. And one of these physicians pointed out that it's commonly non binary kids in their experience who might want to be on puberty blockers for a long time. And one of these physicians says that she's had, I think it was Giordano said that she's had kids say, can I stay on? Like, I don't want any sex hormones because I'm non binary. I don't want to develop in either direction. But unfortunately that's obviously it's not possible. So they have to be taken off puberty blockers. And who knows, maybe that will be more common as more non binary young people present for gender affirming medical care. I think that that's a trend that's increasing, but I still think that in many cases, I don't want to say most because I don't know, but in many cases it's not the kids that need time to think. Which brings me to the CAS review's last big concern. And that's about the effect of puberty blockers on executive function. So there's a researcher called Sally Baxendale. She's a highly regarded neuropsychologist, apparently, but she's also a terf, and so she's very controversial. And she did a systematic review of studies into the effect of puberty blockers on executive function. And there is some, some evidence, though it's exclusively from what the Cass review would call low quality studies, that IQ and executive function may reduce during the use of puberty blockers. Now, almost all of these, well, there were only five studies that she could find that existed on this topic, and I think only one of them was a case study of a single trans femm, and the other were CIS kids with precocious puberty. But still, I would agree with her that if there is. If IQ and executive function reduce with CIS kids who are put on puberty blockers for precocious puberty, then probably that happens when you pause puberty for trans kids too. But my question is, why doesn't Hillary Cass then recommend the same way that Michelle Telfer does, that the kids should be able to access blockers earlier? And so what I think is maybe we should just face up to it like that. It's possible. I mean, look, it makes sense to me that if you go on puberty blockers and you stall puberty at a time when your brain is developing rapidly, that it may stall your brain development. Probably does, and you may therefore fall behind at school for a couple of years or something. I don't know. There aren't enough studies to say. Right. But it makes sense to me. It could be possible. And all the cast review has to do is make these things seem possible. They don't have to convince us, they don't have to convince the public at large that this stuff is happening.

They just have to, well, it's likely.

So the doubt. Right.

Better be careful.

And obviously we would say, well, look, if that child falls into a bit behind at school, but they stay alive, or they get to progress to the gender that your kid's alive.

Oh, wow, that's amazing.

Yeah. Or they get to progress to HRT and feeling at home with their gender, then it's worth it. But it's just more negative publicity. And I don't, I actually wish that we would all just face up to that. Maybe the argument then should not be trying to keep this status quo where we put kids on puberty blockers till 16. It should be arguing that puberty blockers start at 14 or that they start when is relevant to that child. Now I do understand that in the case especially of transmasculine kids they often realise that they're suffering from gender dysphoria later and so then it's harder to, to establish a history of gender dysphoria. And there's reasons for that. I discussed them when we a couple of years ago when we talked about Tay Meadows trans kids book. So I do understand where some of the doubt comes from. But I mean as a starting point, for God's sake, for the kids that have been have known, like for a trans femm who's known that she was transfam since the age of 4 or something, for her to have to wait until 16 to go on HRT is absolutely pointless in my opinion. Yeah, I'm gonna finish there.

No, I'm with you. I'm well and truly with you.

So I had one other thing to say. Well actually one short thing, qualification of what I said earlier, by the way. I'm definitely not advocating for keeping trans masc young people in puberty blocker limbo either. I'm just saying I understand why in some cases if a child has developed gender dysphoria relatively late that that could be something that physicians aren't as confident about. I still think that they could probably get over it. But I did want to say one last thing and that is whereas there are a few low quality studies suggesting that that puberty blockers may have negative cognitive effects, there are other more robust studies suggesting that HRT has positive cognitive effects. So it seems from what few long term observational that I think there's been two longer term studies. One of them shows that there is no dip in educational attainment which isn't the greatest metric I don't think of of trans people who've been on blockers and then progressed to hrt. But there does seem to be anecdotal evidence that HRT tends to solve a lot of the problems that happen also.

You know, it's kind of like one of these things. Sometimes you get medication to treat something and then you have symptoms of that medication and then you get other medication to treat that thing, so.

That's right.

You know, it's complex. It's not always like a straightforward thing. As an ADHD person, you know, I, I'm on Ritalin, I'm prescribed Ritalin for, to help me concentrate. But you know, I also lack appetite. So you know there are side effects of things. But the Ritalin helps me overall feel better and function and get by and you know, do my laundry, things like that. So you know, it's kind of like. And same with binders. Even binders are known to harm and can sometimes crush your, your sternum as you develop. You can develop some issues with breathing with binders. And we know that that's a side effect of binders regardless of how good they are. But the overall well being of that young person to want to live wearing the binder significantly outweighs that. So, you know, it's kind of like.

Weighing these things up. Well, and also I think we could all agree that one thing that does negatively impact cognition is trauma and depression and anxiety. And those things are all going to increase with a child that wants to transition but is denied puberty blockers or hrt.

And I would argue that their happiness is supersedes all else.

I think so too. And I don't like to get in the weeds about Hillary Cass's arguments, but I do sometimes feel like when we don't address them, they just get louder.

Oh absolutely. And I'm glad you're here to wade through the weeds for us. Ben, thank you so much for tuning into Transmission. And thank you to Tamara from Highvale for subscribing to four Triple Z as well this morning. You're amazing.

Yay. Thank you.

We'll leave you on that and have a good week.

Yoo bye.

Thank you so much for listening to Transmission. See you next Tuesday, 9 to 10aM on 4 triple Z.