Treating gender dysphoric adolescents with puberty blockers carries a risk of permanent impacts to their cognitive development amongst other harms. Puberty between the ages 10-16 may be a critical window for brain maturation and supressing puberty for all or some of this period could have permanent effects on cognitive function. The treatment lacks high-quality evidence of beneficial impacts.
A case study of a Brazilian child demonstrated a 10 point drop in IQ following puberty supression (Schneider et al., 2017). An animal study demonstrated a large and sustained reduction in long-term spatial memory following pubertal supression (Hough et al., 2017).
There have been no well-controlled long-term studies on the impacts of pubertal supression on gender dysphoric adolescents but a lack of studies does not imply that the risk is not present.
Puberty blockers are assumed to relieve distress associated with pubertal development of sex characteristics but this assumption lacks evidence. In one of the few available pubertal supression studies the control group, who had more severe mental health problems, showed improved mental health when provided with psychosocial support only (Costa et al., 2015). In a media report one gender dysphoric adolescent describes blockers as "the worst decision I ever made".
Puberty blockers have not been approved for treating gender dysphoria therefore the medical practitioner must gain informed consent. Parents of adolescents under 16 years old will often grant the consent to the medical treatment of their child. To have legal standing this consent must be fully informed as specified in Right 6 of the Health and Disability Commissioner (Code of Health and Disability Services Consumers' Rights) Regulations 1996
Every consumer has the right to the information that a reasonable consumer, in that consumer's circumstances, would expect to receive.
Therefore, if a medical practioner prescribes puberty blockers without informing parents and/or the patient of the risk of impacts to cognitive function, they could be found guilty of professional misconduct. Exemplar consent forms published by the University of Waikato do not mention these risks.
A highly cited case regarding informed consent is Rogers v Whitaker heard by the Australian high Court in 1992. An opthamologist failed to inform a patient that eye surgery on one eye could result in blindness in the other eye (sympathetic ophthalmia) - a 1:14,000 risk.
In the high court's 6-0 decision against the opthamologist the court stated:
...it is part of the doctor's duty of care to disclose “material” risks. A risk is material, if: “in the circumstances of the particular case, a reasonable person in the patient's position, if warned of the risk, would be likely to attach significance to it or if the medical practitioner is, or should reasonably be aware that the particular patient, if warned of the risk, would be likely to attach significance to it.”
The risk of cognitive impacts appears to be much higher than 1:14,000 and would have a material impact on the child's life.
Two of the three studies mentioned above (Schneider et al., 2017; Hough et al., 2017) are open access and have been available for some time. In Hill's (2014) view if the information is published then the practitioner could have taken "reasonable actions in the circumstances to give effect to the rights in the Code".
A charge of negligence requires that the patient demonstrate that a harm has occurred. In the case of cognitive impacts on a developing adolescent this may go unnoticed or be otherwise difficult, though not impossible, to prove. However a charge of professional misconduct requires that the practitioner fail to meet the expected standards of their profession - or importantly - fail to meet community expectations of standards for that profession.
In B v Medical Council of New Zealand the court stated:
The structure of the disciplinary processes set up by the Act, which rely in large part upon judgment by a practitioner’s peers, emphasises that the best guide to what is acceptable professional conduct is the standards applied by the competent, ethical and responsible practitioners. But the inclusion of lay representatives in the disciplinary process and the right of appeal to this court indicates that usual professional practice, whilst significant, may not always be determinative: the reasonableness of the standards applied must ultimately be for the court to determine, taking into account all the circumstances including not only practice but also patient interests and community expectations, including the expectation that professional standards are not to be permitted to lag. The disciplinary process in part is one of setting standards.
Medical practioners cannot simply claim to have followed guidelines on the assumption that guidelines provide legal cover. Do parents expect to know if a treatment could cause their child brain damage? It would be bold of a court to decide that they do not.
If you are an adult and have taken puberty blockers for gender dysphoria, or are the parent of a child who has taken puberty blockers, and you seek assistance with legal and advocacy issues arising from this treatment get in touch.
We are also interested in hearing from medical professionals, lawyers and health policy experts.