Scientific American's departing editor and the politicization of science

> Even shorter periods of puberty blockers will change height, muscle, and skeletal development.

All of which are desired outcomes from the point of view of the patient at the time they request the puberty blockers, and for the duration of the time they keep taking them[1]. You don't conclude an otoplasty is harmful because the patient has less ear afterwards, but you might conclude the practice of otoplasty in minors was harmful if regret was a common outcome. And we know that the proportion of children who choose to cease gender-related treatment, like the proportion of children regretting elective otoplasties, is non-zero[2]. But what Cass absolutely didn't find was evidence to support opponents' presumption that the regret was somehow disproportionate. It just concluded the existing papers on the topic lacked the evidential qualities of some other areas of medical research.

So sure, I'm going to agree there's a good case for raising the quality bar of the existing body of scientific research and doing so carefully, there absolutely is. But that's quite different from concluding that the evidence that is there points to frequency of unwanted side effects seldom found in treatments deemed safe and reversible.

[1]or more specifically, the desired outcome is to prevent more rapid and less reversible physiological changes the patient expressly doesn't want to happen. [2]and in some respects elective otoplasty on minors is more complex: your ears don't rapidly and irreversibly grow if a clinic suggests putting body image aside and deferring the decision until adulthood, and the effects of the surgery are instant, rather than the result of a sustained process where the default is your ear reverting back to roughly the way it would have been was unless you commit to it for an extended period of time.

No, I don't think patients want to have brittle bones that are much more likely to break. I don't think patients wanted to never experience an orgasm. These are not desired outcomes. These are unintended negative side effects of preventing natural puberty.

Again, the claim is that puberty blockers are reversible. A natal male patient that is unsure of their identity and takes puberty blockers for some time then ceases treatment will on average be shorter than if he had never taken blockers. They are not reversible. The effects of puberty blockers are permanent.

The Cass Review found that rates into regretted transition were very limited because they didn't follow up with patients for long periods of time. In particular, the youth gender clinics in the UK didn't follow up with any patients after the age of 18. So when they say that they measured an incredibly low rate of regret, understand that this is a low percentage of patients that reported regret by the age of 18. Someone who started to regret it at 19 or in their 20s is not counted. What the Cass Review found was that bodies like WPATH and AAP were claiming low rates of regret when the evidence base for that claim was extremely weak.

Evidence based medicine doesn't mean we just adopt any anything goes stance until it's been proven that treatment is harmful. Evidence based medicine means we don't give treatment until we have evidence that treat confers good outcomes - at least not outside of a research setting.

I don't think patients who want to be addressed as a women particularly wish to end up 6'4" tall with broad shoulders, but those are unintended side effects of unwanted puberty for a significant number of people currently requesting blockers.

So being smaller is literally an intended effect of choosing blockers. And the relatively small proportion of natal male patients that cease treatment go through puberty, hence the primary effect is not irreversible. Being statistically slightly smaller in stature wouldn't typically be classed as a harmful side effect of any other course of treatment, particularly where the purpose of the treatment was to ensure those choosing to continue successfully avoid more drastic and completely irreversible changes in stature before making a decision on hormones which actually are extremely difficult to reverse. Since we're insisting that WPATH and the AAP's evidence base is a bit thin, I'm sure I'm going to be wowed by the list of citations you produce for puberty blockers causing significant harm in the form of "brittle bones that are much likely to break"...

The Cass Review found that a children's clinic didn't conduct followup exercises with adults and didn't regard other followup studies involving adult cohorts as conclusive. I haven't disputed that, or that medicine is typically more cautious than other sciences. What I am disputing is that the Cass Report concluded that puberty blockers were dangerous and irreversible when prescribed to people with gender dysphoria. I mean, if she actually believed that had been established, she wouldn't be recommending trials, right...

> I don't think patients who want to be addressed as a women particularly wish to end up 6'4" tall with broad shoulders, but those are unintended side effects of unwanted puberty for a significant number of people currently requesting blockers.

For the third time your claim was that puberty blockers are reversible. This is false. If this hypothetical child decided to stop taking puberty blockers, the impact on height would not be reversed. He would not reach the same height if he took blockers and stopped than if he never took blockers at all. Puberty blockers are not reversible.

And again, impacts on bone density and inability to achieve orgasm are most certainly not desired and these side effects go entirely unmentioned in your response. I don't know why you imply there's no research on these side effects:

https://pmc.ncbi.nlm.nih.gov/articles/PMC9578106/#:~:text=Re....

> Results consistently indicate a negative impact of long-term puberty suppression on bone mineral density, especially at the lumbar spine, which is only partially restored after sex steroid administration. Trans girls are more vulnerable than trans boys for compromised bone health.

https://pmc.ncbi.nlm.nih.gov/articles/PMC9886596/#:~:text=Pu....

> Puberty blockers, cross-sex hormones and genital surgery also pose risks to sexual function, particularly the physiological capacity for arousal and orgasm. It is important to be aware there is a dearth of research studying the impact of GAT on GD youth’s sexual function, but I provide a brief discussion of this important topic. Estrogen use in transwomen is associated with decreased sexual desire and erectile dysfunction and testosterone for transmen may lead to vaginal atrophy and dyspareunia

I'm not sure why you think that bringing up a survey showing moderately reduced bone density following long term puberty suppression and transition (sonething actually referenced by Scientific American, along with a note the cause/effect wasn't settled given that gender dysphoria sufferers also tend to have smaller bone structure than average before starting treatment, plausibly due due exercise effects) is evidence of "brittle bones that break more often" being a significant risk factor, which is your actual claim. For the third time, my point is that the Cass Report concluded that the evidence base that found the treatment safe and regret rates low didn't meet the highest possible bar for quality and coverage, and did not offer supporting evidence of the greater merit of claims made to promote the idea that puberty blockers were unsafe when used for gender dysphoria, relative to other treatments or other use of the same treatment, such as wild insinuations about bone-breaking being a common side effect of their temporary use...

For similar reasons, studies which shows erectile dysfunction is not uncommon in patients who have chosen to continue treatment using oestrogen, (universally agreed to have irreversible consequences; it's literally the point of using puberty blockers rather than going straight to sex hormones) is not a high standard of evidence that using puberty blockers for a few months aged 11 is significantly less reversible than using for a year or two aged nine. The actual claim being made: that the treatment is reversible in the sense that children are able to come off it and go through puberty, isn't really being contested here either.

> The actual claim being made: that the treatment is reversible in the sense that children are able to come off it and go through puberty, isn't really being contested here either.

By this logic cross sex hormones are reversible too: someone can stop taking artificial estrogen and stop taking anti-androgens and their body will resume production of natural hormones. You can come off cross sex hormones just like you can come off puberty blockers, under your interpretation of the word "reversible". But that's obviously not what people are talking about when they describe treatment and reversible.

Puberty blockers do indeed leave permanent effects. Yes, you can go off puberty blockers. But years of skipped puberty will have permanent effects. Puberty blockers are as reversible as cross sex hormones: yes, you can stop taking them and resume your body's normal hormone production but the time spent altering hormones will have permanent effects.

The descriptions of puberty blockers promulgated by activist groups like mermaids were so misinformed that the UK government has to force them to change their language: https://www.theguardian.com/society/2024/oct/24/trans-childr...

> The watchdog asked Mermaids to review its position on puberty blockers, particularly a section on its website stating that the effects of the treatment were reversible. The Cass review found that the evidence base on puberty blockers was “weak”; puberty blockers will now only be prescribed as part of a NHS clinical trial. Mermaids has removed text stating that puberty blockers are an “internationally recognised safe, reversible healthcare option”.

Parents were told for over a decade that puberty blockers were just like a pause button on puberty. Unpause, and puberty would play out and leave their child just like if they had never gone on blockers. This is not the case, and the unfortunate reality is that many parents consented to treatment on account of misinformation.