A Question of Informed Consent
We welcome the willingness of the BMJ to publish discussion around the treatment of children with gender dysphoria and in particular around the concerns that have been raised regarding the puberty blockers study (1). Although the outcome of the HRA investigation concluded that researchers did not veer from research norms we are left with significant questions over the appropriateness of the use of puberty blockers in children with gender dysphoria.
Gender dysphoric children and teens are experiencing a crisis of identity. All young people generally struggle to think about the long term consequences of life choices. It is no surprise therefore that questions are raised over the ability of these young people to make decisions with meaningful and informed consent. This is especially true of interventions that have unknown long-term outcomes (2)
Gonadotrophin Releasing Hormone Agonists (GnRHa) are generally given under the premise that they provide “breathing space” for a child or young person to explore their identity without the distress caused by pubertal changes (3). However it is becoming clear that once started on GnRHa to block puberty almost all children go on to receive cross-sex hormones (4). The information given to parents and children that puberty blockers are completely reversible and just give breathing space might therefore be construed as misleading.
Further concern around informed consent is highlighted by the increasing number of young adults coming forward to express their wish to “detransition” (5). These young adults have undergone varying degrees of social, medical and surgical transition before coming to a realisation that they do not want to identify as the opposite sex and want to accept and reconcile with their natal sex. These young people cite untreated mental health problems including depression and self harm as well as awareness of same sex attraction as reasons to transition initially. Studies show over-representation of major mental disorders, bullying and same sex attraction in adolescent gender clinic populations (6,7)
Children and Young People deserve detailed psycho-social assessment, treatment for other co-morbid conditions and the best evidence-based treatments. We need to be able to explore and debate these issues so that these vulnerable children can get the help and support that they need.
1. Cohen D, Barnes H. Gender dysphoria in children: puberty blockers study draws further criticism. BMJ. 2019 Sep 20;l5647.
2. Heneghan C. Evidence Spotlight: Gender-affirming hormones in children and adolescent [Internet]. BMJ; 2019. Available from: https://blogs.bmj.com/bmjebmspotlight/2019/02/25/gender-affirming-hormon...
3. World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People Version 7 [Internet]. 2012. Available from: www.wpath.org/publications/soc
4. de Vries ALC, Steensma TD, Doreleijers TAH, Cohen‐Kettenis PT. Puberty Suppression in Adolescents With Gender Identity Disorder: A Prospective Follow‐Up Study. J Sex Med. 2011 Aug;8(8):2276–83.
5. Female detransition and reidentification: Survey results and interpretation [Internet]. 2016. Available from: 40. http://guideonragingstars.tumblr.com/post/149877706175/female-detransiti...
6. Kaltiala-Heino R, Sumia M, Työläjärvi M, Lindberg N. Two years of gender identity service for minors: over representation of natal girls with severe problems in adolescent development. Child Adolesc Psychiatry Ment Health. 2015 Dec;9(1):9.
7. Holt V, Skagerberg E, Dunsford M. Young people with features of gender dysphoria: Demographics and associated difficulties. Clin Child Psychol Psychiatry. 2016 Jan;21(1):108–18.
Competing interests: No competing interests