Article by Magali Pignard published on her website https://www.transition-mineurs.com/
24 January 2025
trad. DeepL-ChatGPT
While the British Labour government bans the sale of puberty blockers because of their ‘unacceptable safety risk’, an ‘expert consensus’ among French endocrinologists recommends them as a 1st-line treatment, just like cross-sex hormones: Ignoring systematic reviews of the evidence and the Cass Review, they claim that children with very little sexual/life experience can ‘understand the implications’ of a treatment with unknown long-term effects, which will impact their whole lives with a risk of infertility/sterility/sexual dysfunction, at a time when their identity is in full construction and their priorities are largely likely to change. |
In a recent article (Brezin et al., Nov. 2024), a ‘working group’ of the SFEDP (Société Française d'Endocrinologie et de Diabétologie Pédiatrique) describes its recommendations for the endocrine management of adolescents who identify themselves as transgender. These are in contrast to the Cass Review (the most comprehensive assessment of the practice of gender medicine in young people), which is not cited. Based on the belief that gender dysphoria cannot be resolved naturally, the authors recommend, without delay, puberty blockers and cross-sex hormones as 1st-line treatment: invasive and often irreversible interventions, not supported by the systematic reviews of the evidence (grouped together in this post): moreover, it seems that the authors are not aware of these studies (which represent the highest level of quality studies), despite their call for young people to have access to information that is ‘as informed as possible’.
This French ‘Expert Consensus’ contrasts with the official opinion of British medical experts from the Commission for Medicinal Products for Human Use, who consider that ‘the continued prescription of puberty blockers to children currently presents an unacceptable safety risk’. Following this advice, the Labour government has continued to ban the sale and supply of puberty blockers indefinitely.
Rather than relying on robust evidence, the authors follow the latest guidelines from the Endocrine Society (2017) and WPATH (Standards Of Care 8 2022): these are linked by co-sponsorship and have influenced almost all existing guidelines, creating, despite weak evidence, a misleading consensus by referring to their own guidelines through circular referencing (Taylor et al. 2024).
Furthermore, court documents unsealed in June 2024 revealed that when developing their guideline, WPATH failed to follow the principles of evidence-based medicine, removing evidence that could negatively impact access to sex reassignment treatments, particularly in minors.
Selon ce groupe :
gender dysphoria in adolescents cannot resolve itself, despite recent studies showing the opposite,
endocrine treatment is the only option for reducing psychological distress, whatever its cause, and promoting psycho-affective and cognitive development affected by a state of depression, even though the effects of blockers on cognitive development are unknown, and the positive impact of this treatment on mental health is not supported by existing evidence.
not giving these treatments increases the risk of suicide, which is also not supported by existing evidence.
children with little or no sexual experience may consent to puberty blockers in particular: these will in particular suppress all sexual desire (chemical castration) at the time of their first romantic relationships, with a risk of making them fertile/sterile in adulthood if they continue with cross-sex hormones, which is very often the case, as the authors acknowledge.
The authors repeatedly mention the importance of obtaining informed consent, whereas:
• The conditions necessary for obtaining such consent should include the exploration of all alternatives (which the authors do not bother to do);
• Clinical decision-making is a challenge: the Cass Review, which dedicated an entire chapter to this issue, states in its final report that “the duty to communicate information is complicated by numerous unknown factors regarding the long-term impacts of puberty blockers and/or masculinizing/feminizing hormones during a period of dynamic development where gender identity may not be fixed” (16.18).
Guidelines of This Working Group
Referring to the WHO, which has not made a decision regarding minors
The SFEDP refers to the WHO, even though the WHO has not made a decision concerning children and adolescents, stating that “the evidence base on children and adolescents is limited and variable regarding the long-term outcomes of gender-affirming care for children and adolescents” (January 15, 2024).
Ignoring guidelines that do not align with the desired direction
To develop its recommendations, the working group:
• Ignores guidelines focused on individual safety, such as the Finnish and Swedish guidelines, which are the only ones to have obtained a score >50% for rigor and development in the systematic review of international guidelines (Taylor, 2024).
• Ignores the Cass Review, whose recommendations are based, among other things, on the most extensive systematic reviews to date, which are entirely absent from the article. It is worth noting that the Cass Review has been fully accepted by the NHS, supported by the two main British political parties, and widely adopted by the British medical community.
Adapting the Recommendations of WPATH (2022) and the Endocrine Society (2017)
The SFEDP working group follows the approach of medical organizations in the United States, to which it briefly refers: it models its recommendations on the trans-affirmative guidelines of WPATH (2022) and the Endocrine Society (2017), whose scores for rigor and development are 35% and 42%, respectively (systematic review by Taylor, 2024).
This review demonstrated that these organizations are interconnected through co-sponsorship:
• WPATH (2022) heavily relied on ES (2017),
• ES (2017) played a direct role in the development of WPATH (2012) (score: 26%),
• WPATH (2012), in turn, was largely based on ES (2009) (score: 44%).
(See figure below)
The Cass Review, ignored by this working group, highlighted the problematic nature of this circular referencing, stating that “the circularity of this approach may explain why there has been an apparent consensus on key areas of practice despite the weakness of the evidence.”
The working group’s approach thus misleads healthcare professionals and the public, leading them to believe in the validity and reliability of recommendations that are based on weak evidence.
WPATH at the Center of a Scientific Scandal
WPATH Controlled the Content of the Systematic Reviews It Commissioned for Its 2022 Guidelines
This suppression of evidence was revealed through internal communications subpoenaed as part of a lawsuit in Alabama, USA. These communications relate to the development process of their “Standards of Care 8” (2022), and a portion has been unsealed so far.
To develop its guidelines, WPATH commissioned multiple systematic reviews of evidence from Johns Hopkins University (JHU)—specifically from the Evidence-Based Practice Center, a leading institution in this field.
First, these exchanges reveal that the leaders of at least one chapter of the guidelines deliberately chose not to have evidence reviewed by JHU, stating:
“Our concerns, shared by the social justice attorneys we have spoken with, are that an evidence-based review will reveal little or no evidence and put us in an untenable position regarding policy impact or winning lawsuits.” (Exhibit 174, p. 131)
WPATH Considered the Systematic Reviews as Its Property and Therefore Interfered with Their Content
When the Johns Hopkins University (JHU) team submitted the first three systematic reviews to WPATH for publication, one of them was indeed published (Wilson et al., 2020). However, regarding the other two, WPATH leadership was “caught off guard” (Exhibit 1, p. 14/15), likely because the conclusions of these reviews did not support their objectives.
In a letter to JHU (August 26, 2020), WPATH explained that these reviews raised “numerous concerns”, particularly because they did not involve “a WPATH leader in the design, drafting, and final approval of the article.” (Exhibit 1, p. 2/15)
WPATH then decided to “put on hold” the publication process for these systematic reviews (the specific ones remain unknown).
Five days later, the head of the JHU evaluation team explained in an email to a representative of a government agency (AHRQ) that they were “having problems with this sponsor [WPATH] attempting to restrict our ability to publish.” She further stated that their team had found “little to no evidence regarding children and adolescents.” (Exhibit 173, p. 23/142)
Subsequently, the WPATH exercised editorial control by introducing an ‘approval policy’ for future systematic reviews (Exhibit 1, pp. 6-11/15): the WPATH had to approve the conclusions of each systematic review project (in draft form); the authors had to intend to use the data ‘to advance the health of transgender people in a positive way’ as defined by the WPATH; a WPATH officer had to be involved ‘in the conception, drafting and final approval of the article’. (Exhibit 1, p. 6/15). This check for approval by WPATH took place at 2 levels: after the 1st submission for publication (in draft form), and when the manuscript was ready for publication.
On 20 October 2020, the outgoing WPATH chair wrote to the chapter authors and the UJH team, stating that the research needs to be ‘scrutinised and reviewed in depth to ensure that the publication does not adversely affect the provision of healthcare for transgender people in the widest sense’. (Exhibit 1, p. 14/15). The Chair states that ‘These systematic reviews are the property of WPATH’.
The Head of the Evidence Review Team Condemned This Process
The head of the Johns Hopkins University (JHU) team responded the same day, stating:
“WPATH approval for our publications is not required under the terms of the agreement, WPATH policy was not incorporated into the executed agreement, so it does not bind us, and JHU institutional policies on academic freedom and intellectual property prohibit such restrictions or approval requirements regarding publication. (…) Retaining the right is not the same as ownership, and it does not preclude that JHU also holds the same rights over the project data. We have the right to publish, and any JHU publication resulting from the work conducted under this contract is not subject to WPATH approval or any WPATH policy. We will continue to send draft manuscripts to WPATH for review and will take into account any feedback received. (…)” (Exhibit 1, p. 12-13/15).
Summary
In total, only two systematic reviews were published: one was released before the policy change (Wilson et al., 2020). After the policy was implemented, only one other review was published (Baker et al., 2021). This was the only evaluation to pass WPATH’s approval process, despite the existence of “dozens” of reviews conducted by the Johns Hopkins team, as revealed in the court documents.
No systematic review therefore concerns adolescents.
Subsequently, WPATH stated in its “Standards of Care” SOC8 (2022) (Adolescents chapter) that a “systematic review is not possible” due to the low number of studies. However, it unreservedly recommended puberty blockers and cross-sex hormones, justifying this by claiming that existing studies demonstrated their benefits.
In Detail: Arguments Presented by the SFEDP Working Group
Children Are Capable of Consenting to This Treatment
The authors support their argument with a study that attempted to assess the decision-making capacity of adolescents seeking medical transition by administering the MacCAT-T questionnaire to adolescents with a mean age of 14.7 years (Vrouenraets et al., 2021). They concluded that adolescents were capable of consenting to the initiation of puberty suppression.
However, as Levine, Abbruzzese, and Mason (2022) point out, this questionnaire was not designed for children, but rather to assess the consent capacity of adults with dementia, schizophrenia, and other psychiatric disorders. The two contexts are not comparable: these children lack the life experiences necessary to give informed consent to medical interventions that will affect their entire lives, including their future relationships.
It is highly questionable whether children who have not had sexual experiences can fully comprehend the potential loss of their sexual functions and future reproductive capabilities.
It is worth recalling that the High Court in England (December 2020) ruled that children under 16 are unlikely to fully understand the long-term effects of treatment and provide informed consent.
Citing the fact that the vast majority of young people on puberty blockers proceed to cross-sex hormones (the systematic review of care pathways by the University of York (Taylor, 2024) found that only 0 to 8% of youth discontinued puberty suppression), the High Court suggested that children/adolescents should understand the consequences of a full transition process in order to consent to puberty blocker treatment.
The court concluded that it is “highly unlikely that a child of 13 or younger could consent to treatment” and that it is “doubtful that a child of 14 or 15 could understand the consequences”.
Consenting to Never Experiencing Sexual Pleasure?
The authors emphasize the importance of informing 11–12-year-old boys who are candidates for puberty blockers that their use “may alter the possible surgical techniques if they later wish to undergo vaginoplasty.” Indeed, by the time they reach the age for vaginoplasty, their penis will have the size and sexual maturity of an 11–12-year-old child. As a result, there will not be enough penile and testicular tissue to create a vaginal cavity and clitoris. In such cases, intestinal tissue is used to construct a vagina.
The president of WPATH, Marci Bowers, has acknowledged that boys who start puberty blockers at the very onset of puberty will be anorgasmic adults if they continue with lifelong estrogen therapy and undergo vaginoplasty (Symposium, Duke University, 2022, The Free Press, April 21).
How can an 11-year-old child with no sexual or romantic experience possibly comprehend the implications of this choice, which will likely deprive them of ever experiencing sexual pleasure and affect their future romantic relationships for life?
Professionals Admit Among Themselves That These Children Cannot Consent
Experienced professionals in the care of children with gender dysphoria acknowledge among themselves that these children are not capable of informed consent:
‘It's always good in theory to talk about fertility preservation with a 14-year-old, but I know I'm talking to a brick wall (...) I still don't know what to do for 14-year-olds. Parents think about it, but 14-year-olds, you know... It's like talking about diabetes complications with a 14-year-old. They don't care. They're not going to die. Dr Dan Metger Paediatric endocrinologist at BC Children's Hospital in Vancouver, member of WPATH
‘[Regarding children and adolescents] It's a bit of a developmental aspect, it's outside their developmental range sometimes to understand to what extent some of these medical interventions impact them.’. Dianne Berg, Child Psychologist and co-author of the children's chapter of WPATH Standards of Care 8
Source : Workshop : Evolution of Identity, May 6, 2022
Giving Consent While Being Deprived of the Ability to Make Complex Decisions?
Another issue concerns children on puberty blockers who must give consent to receive cross-sex hormones. These blockers not only inhibit the development of sexual characteristics but also disrupt normal brain maturation that occurs during puberty. This maturation is crucial for decision-making processes.
According to the Cass Review:
“There are also concerns that blockers may alter the trajectory of psychosexual development and gender identity (83). (…) Brain maturation may be temporarily or permanently disrupted by the use of puberty blockers, which could have a significant impact on a young person’s ability to make complex decisions involving risks, as well as potential longer-term neuropsychological consequences (14.38).”
Sallie Baxendale, author of a review on the impacts of puberty suppression on neuropsychological function (Feb. 2024, not mentioned by the authors of this article), states:
“Puberty is the neurodevelopmental process that literally builds the neural architecture allowing individuals to think about complex and nuanced issues. Blocking puberty prevents the crucial rewiring of the brain that underpins the ability to make complex decisions. Puberty blockers may give children time to think, but they simultaneously deprive them of the ability to do so.” (UnHerd, March 20, 2024).
Two other aspects not taken into account
According to the authors, informed consent is obtained when the young person is capable of giving consent, but this is only one aspect: two other aspects must be taken into account:
Determining Which Treatment Options Are Appropriate
This step is skipped by the authors. However, the Cass Review states that:
“One of the most difficult ethical questions is whether and/or when medical intervention is the appropriate response. (…) A person’s maturation continues until the mid-20s, and during this period, gender and sexual identity may continue to evolve. Priorities and experiences during this time are likely to change. (…) For these reasons, many clinicians consulted in the review, both nationally and internationally, stated that they cannot reliably predict which children/young people will have a successful transition and which may regret or reverse their decision at a later date.” (16.9–16.11)
Providing the Information Patients Need to Make an Informed Decision About Proposed Options
The information provided to individuals is based on studies with various methodological issues and long-term unknowns, as acknowledged by the authors. As the Cass Review highlights:
“When considering endocrine interventions, the large number of unknowns regarding risks/benefits for each individual and the lack of robust information to support decision-making pose a major challenge in obtaining informed consent. (16.34) (…) Information [on the long-term benefits and risks of hormonal interventions based on outcomes from other individuals] is currently unavailable for interventions in children and young people (…), meaning that young people and their families must make decisions without having an adequate picture of potential impacts and outcomes. (…) (90)”
The authors reiterate that “the best interest of the child is a reference point in decision-making.” However, as the Cass Review states:
“Best interest decisions are particularly challenging when the proposed treatment has a significant impact, is difficult to reverse, and when the outcome of the treatment is less predictable.” (16.33)
Gender dysphoria cannot resolve itself and any non-endocrine intervention is a ‘wait and see’ attitude.
This belief has never been properly tested (Abbruzzese et al. 2023), and there is growing evidence to contradict it (Bachmann et al. 2024, Sapir, 2024). As the Cass Review points out, ‘A formal diagnosis of gender dysphoria is often cited as a prerequisite for access to hormonal treatment. However, it is unreliable in predicting whether this young person will have a lasting gender incongruence in the future, or whether medical intervention will be the best option for them’ (16.8).
Puberty blockers improve mental health
To make their point, the authors are careful not to cite systematic reviews of the evidence: these conclude that the level of certainty regarding the favourable impact of endocrine treatments in minors is low, meaning that ‘the actual effect could be very different from the estimated effect’.
Instead, this group cites studies whose quality has been assessed as low to very low by systematic reviews (SR) of the evidence (see table below), with the authors nevertheless mentioning that ‘not all changes are significant and that there are methodological limitations in the studies’.
The authors also cite Chen 2023, which does not concern puberty blockers but cross-reactive sex hormones. Not evaluated by the RS, commented in detail by Jesse Singal 2023 (see article in French).
It's important to put all this into context: although the benefits of puberty blockers and cross-sex hormones are deeply uncertain, the health risks can be potentially serious. Infertility and sexual dysfunction are the most widely recognised risks, especially when pubertal suppression is followed by cross-sex hormones, with the authors acknowledging that this is almost always the case. However, there are many other risks, including: cognitive impairment (see review by Sallie Baxendale, 2024); problems with bone density (see, for example, van der Loos et al., 2023); and increased risk of cancer and cardiovascular disease (see Natalie J. Nokoff et al., 2021).
Not Providing These Treatments “Increases the Risk of Suicide”
The authors support their argument with two studies (Tordoff, 2022; Turban, 2020), which have been rated as low quality in existing systematic reviews, showing serious risks of bias, and have been debunked multiple times.
However, according to the Cass Review:
“The evidence does not adequately support the claim that gender-affirming treatment reduces the risk of suicide.” (15.43)
The best available evidence (Finnish cohort study) suggests that the risk of suicide is attributable to comorbid mental health conditions, not gender dysphoria itself, and that:
“Medical sex reassignment has no impact on suicide risk.” (Ruuska et al., 2024)
The Only Recommended Treatment Option Is Justified by the Claim That “the Percentage of Young People or Adults Who Have Detransitioned Remains Low, at Around 1 to 6%”
To support this claim, the authors cite, among others:
• Wiepjes et al. (2018) – This study presents several issues that bias the reported regret rate:
• Inadequate measurement of regret (individuals who only took cross-sex hormones and underwent mastectomy were not counted).
• Regret had to be expressed during exchanges with gender clinic professionals, whereas a study has shown that most detransitioners do not inform their gender clinic of their detransition (Littman, 2021).
• Short follow-up period.
• Different population profile from the current one.
• Significant loss to follow-up. (More details on this study in the fact-checking section.)
• Olson et al. (2022) – This study actually shows that early social transition can lead to the persistence of gender dysphoria in children. As noted in the Cass Review:
“Those who had socially transitioned at an earlier age and/or before being seen in a clinic were more likely to follow a medical pathway.” (76)
• Roberts et al. (2022) – This study suggests a detransition rate of up to 30%, which is far from the claimed 1 to 6%.
The Actual Rate of Detransition Remains Unknown
As concluded by Cohn (2023), what is missing is long-term follow-up of large groups of trans-identifying individuals over time, with profiles similar to those of today’s trans-identifying youth, using an appropriate instrument to measure regret and minimizing loss to follow-up. Such studies do not yet exist.
The Cass Review notes:
“The percentage of people treated with hormones who have subsequently detransitioned remains unknown due to the lack of long-term follow-up studies, although there are indications that this number is increasing.” (87)
Puberty Blockers Are Indicated for Gender Dysphoria Because They Have Long Been Used for Precocious Puberty
This is true, but there is a significant difference:
• When prescribed to delay precocious puberty (occurring before ages 8–9), they allow for a normal developmental trajectory. They do not suppress sexual desire at the time of first romantic relationships, do not impact future reproductive capacity, and do not affect cognitive and bone development.
• When used to block normal puberty, they prevent a normal developmental trajectory. They suppress sexual desire (chemical castration) at the time of first romantic relationships (boys who take blockers at the onset of puberty will very likely be anorgasmic adults if they continue lifelong estrogen therapy and undergo vaginoplasty (Bowers, 2022)). They affect future reproductive capacity if followed by cross-sex hormones, which is the case for the vast majority of young people undergoing this treatment (Taylor, 2024 – systematic review on care pathways). The long-term impact on cognitive and bone development remains unknown.
On this subject, Dr. Cass stated in an interview:
“There have been extensive studies on the use of puberty blockers just to stop very early puberty. And then, when their puberty resumes at a later time, all the long-term studies have been very reassuring, which is why they are approved for this group.
This is a very different situation from a young person whose hormones are undergoing the normal expected increases during puberty and putting that on pause.
Because during puberty, all sorts of things are happening. Your brain is developing very rapidly. You develop what’s called executive function, which allows you to handle complex problem-solving and complex judgment abilities. You are also developing your sexuality and identity. And we simply do not know what happens if you put the brakes on all of that.” (WBUR, May 8, 2024)
Puberty Blockers Do Not Affect Cognitive Development?
The authors support this claim by citing two studies:
1. Staphorsius et al. (2015) – U.S. Study on 20 Youths on Puberty Blockers
• Evaluated by the systematic review conducted by NICE (2020): Rated as “low quality” according to the Newcastle-Ottawa scale.
“This study provides very low-certainty evidence (without statistical analysis) on the effects of GnRH analogs on cognitive development or functioning. No conclusions could be drawn.”
• Evaluated by the systematic review of the University of York (Taylor et al., 2024): Rated as low quality according to the Newcastle-Ottawa scale.
• Evaluated by the Swedish systematic review (Ludvigsson et al., 2023): The certainty of the evidence could not be assessed.
• GRADE deductions: 2/4 for risk of bias, 2/4 for precision.
“Since no before-and-after analysis of GnRHa therapy was conducted, the study could not examine the potential cognitive effects of hormone therapy.”
2. Arnoldussen et al. (2022) – Dutch Study on 72 Youths on Puberty Blockers
• Not evaluated by existing systematic reviews but included in Baxendale’s 2024 literature review:
“Arnoldussen et al. reported the results of an IQ assessment before the start of GnRH analogue treatment in 72 children and examined the relationship between this measure and a highly simplified and dichotomized index of educational progress/success (‘professionally educated’ vs. ‘higher professional/academic education’). Before treatment, the mean and standard deviation of IQ scores in the group were comparable to the general population (mean = 100, SD = 15).
40% of eligible subjects refused to participate in the follow-up. No conclusion can be drawn from this study regarding the impact of puberty suppression on cognitive function development.”
Existing Systematic Reviews on the Neuropsychological Impact of Puberty Blockers
• Overall conclusion: “It is impossible to draw conclusions.”
• Baxendale’s literature review (2024) states:
“Crucial questions remain unanswered regarding the nature, extent, and permanence of any disruption in cognitive function development associated with puberty blockers.”
Experimental Nature of Treatment & Informed Consent
The authors themselves acknowledge that “there are no long-term data yet,” confirming the experimental nature of these treatments. However, this does not prevent them from claiming that children can provide informed consent, despite the unknowns regarding long-term impact.
The Administration of Puberty Blockers Is a Common Clinical Practice
The authors state that puberty blocker treatment has “become a common clinical practice,” which may lead the reader to believe that this is a well-established practice. However, this is not the case.
Since the 2010s, minors have been receiving medical treatments to alter their sexual characteristics, based on the results of a Dutch experiment initiated in the late 1990s, known as the Dutch Protocol. This “innovative practice” was documented in two studies (2011 and 2014) that concluded puberty blockers improved general functioning and reduced depressive symptoms.
However:
• These results have been unsuccessfully replicated twice:
• In England: The Early Intervention Study (Carmichael et al., 2021) produced preliminary results (2015–2016) that showed no benefit. The full study results were only formally published in 2020, as the authors were reluctant to publish them.
• In the U.S.: A large-scale study was launched in 2015, funded by the National Institutes of Health (NIH). Researchers tested puberty blockers on 95 children (see psychosocial cohort characteristics: Chen et al., 2020). The lead investigator refused to publish the results because there were no mental health improvements, and she did not want their work “to be used as a weapon” (New York Times, October 23, 2024).
• Numerous researchers have highlighted the methodological weaknesses of the two Dutch studies and the inapplicability of the protocol to the current population.
• Abbruzzese et al. (2023) describe the adoption of these interventions in clinical practice as an “uncontrolled diffusion” (Earl, 2019) of an innovative practice without passing through a clinical research framework:
“The ‘positive treatment’ approach based on hormones and surgery has rapidly become entrenched in general clinical practice worldwide, without the necessary rigorous clinical research to confirm its supposed robust and lasting psychological benefits. Nor has it ever been demonstrated that these benefits are substantial enough to outweigh the burden of lifelong medical dependence, infertility and sterility, and various physical health risks.”
The Cass Review states:
“It often takes many years for strongly positive research findings to be integrated into practice. (…) The exact opposite has happened in this field. Based on a single Dutch study suggesting that puberty blockers might improve the psychological well-being of a narrowly defined group of children with gender incongruence, the practice rapidly spread to other countries. (…) and to a broader group of adolescents who would not have met the inclusion criteria of the original Dutch study.” (p. 13)
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