Mythbusting

On this page you will find information on how to combat common myths about trans young people. Whether you are talking to the media or to your transphobic uncle, this page will assist you in making evidence-based arguments and fighting disinformation.

Gender-affirming care

Gender-affirming care (GAC) refers to both medical and psychological treatments that affirm trans young people’s identities. At its most basic, it’s about physicians believing young people when they say who they are. For some trans young people, talk therapy might be all that’s required to help them come to terms with their identity (but never to “cure” them of it – more on that later). Others may require hormone therapy, and eventually gender-affirming surgeries. There is no one-size-fits-all treatment.

Gender-affirming medical treatment (GAMT) refers specifically to treatments like puberty blockers (GnRHa, or gonadotropin-releasing hormone analogues) and gender-affirming hormone treatment (GAHT), which assist in medical transition, that is in aligning a young person’s body with their gender identity (ie, their inward sense of their own gender). GAMT can also include surgeries, but chest-reconstruction surgery (“top surgery”) is the only surgery performed on trans young people, and only on a very small number of late-adolescents with appropriate support.

GAMT is safe, evidence-based, and endorsed by the majority of professional medical organisations in Australia and throughout the western world. Organisations that have issued statements in support of gender-affirming care include:

The World Professional Association for Transgender Health (WPATH)
The Australian Professional Association for Transgender Health (AusPATH)
The Australian Medical Association
The Royal Australian College of General Practitioners
The Royal Australasian College of Physicians
The Endocrine Society of Australia
The Australian Psychological Society
The Royal College of Pathologists of Australasia
The Royal Australian and New Zealand College of Psychiatrists
The American Medical Association
The American Psychological Association
The World Health Organisation
The World Medical Association
The Endocrine Society

Nonetheless, these days there is an awful lot of talk about GAC for trans young people, often from those who know least about it. Since the mid-2010s, a concerted disinformation campaign has been in progress targeting the rights of trans young people to access treatment. A handful of outlier physicians, most of whom have no experience in treating trans patients, have managed to create the illusion of a grassroots movement opposed to the expert medical consensus. Remember when climate denial blew up? If so, then this should seem familiar.

Below are some facts about GAC for trans young people, along with some commonly cited myths.

Puberty blockers

What are puberty blockers?

Puberty blockers are medications used to suppress the production of sex hormones. This stops the irreversible development of secondary sex characteristics that are often distressing to trans young people (eg, menstruation, voice deepening, chest growth, facial hair, etc).

In some cases, this is done to give young people, their families, and their clinicians time to decide which next steps are right for the young person.

In other cases, it is clear what next steps are best, but the law does not allow young people to proceed to gender-affirming hormone treatment immediately. In such cases the young person’s physical development is paused until they are old enough to access further treatment.

Puberty blockers do not cause any permanent changes. This is why they are perfect for young people and families who are uncertain, and for doctors and legislators who fear young people may change their minds. (Very few young people do change their minds though – more on that later.)

While all medications have potential side effects, puberty blockers have been safely used to treat precocious (early) puberty in young people since the 1970s, and to treat trans young people since the 1980s. (It’s worth noting that the Queensland government has not banned blockers for cases of precocious puberty.)

Puberty blockers are best prescribed for trans young people at the start of puberty, generally from age 11-14. This helps young people avoid more invasive medical treatments in the future (eg, top surgery, electrolysis, laser hair removal, voice feminisation surgery, facial surgery, etc), since it prevents their bodies developing in ways that do not align with their identities.

For some trans young people, the trauma of being forced to endure their endogenous puberty (ie, the puberty aligned with their gender presumed at birth) can be life-threatening. It’s sad to say, but “passing” (ie, being widely seen as the gender they identify as) can mean the difference between acceptance by peers and widespread harassment for trans young people. In addition, some young people may suffer crippling gender dysphoria (ie, distress associated with gender incongruence) at not being able to see their true selves reflected in the mirror.

On the other hand, if they are allowed to access puberty blockers, and ultimately gender-affirming hormones, in a timely fashion, trans young people can flourish.

A 2024 study compared 40 trans adolescents receiving blockers to 398 trans adolescents who had not accessed blockers. It found those who accessed blockers had lower anxiety, less depression, less stress, and were significantly less likely to report any suicidal thoughts.

Common myths about puberty blockers

Some people claim there is not enough evidence to support their usage for trans young people

This is a misinterpretation of science.

Systematic reviews are overviews of the existing research on a topic, often used by health organisations in developing medical guidelines.

The GRADE system is a common way of rating the certainty of a body of evidence, often used in systematic reviews. In the GRADE system, bodies of evidence are rated “high”, “moderate”, “low”, or “very low” certainty to reflect the confidence of the researchers that the effects claimed by the research will be reproducible in every instance.

There are many reasons a systematic review might rate a body of evidence “low certainty”, but in the case of puberty blockers some of the main reasons are:

A perceived risk of bias stemming from small cohort sizes. (Very few trans young people access puberty blockers.)
Difficulty in isolating the effects of puberty blockers. (Most trans young people accessing blockers proceed directly to GAHT.)
The prioritising of randomised controlled trials as the highest form of evidence by the GRADE system. (In an RCT there is a control group that does not receive treatment, but this would be unethical in the case of a potentially life-saving medication like puberty blockers. Also, blinding is necessary in an RCT to reduce bias, but you can’t blind an RCT of puberty blockers because it would very soon be obvious to both participants and researchers who was on the blockers and who was not. This would also mean that many participants denied blockers would withdraw from the study – high dropout rates are another source of bias – and/or seek blockers outside of the trial.)
The big one: systematic reviews of the use of blockers for gender incongruence often search for effects – such as mental health improvements and reductions in gender dysphoria – that blockers are not intended to achieve. This is because puberty blockers do not change a young person's secondary sex characteristics to affirm their gender identity, they simply pause unwanted changes. This misunderstanding is one of many reasons why we need more involvement from both trans people and experts in trans healthcare when it comes to researching GAMT.

Therefore, when people claim there is “not enough evidence” to support the use of puberty blockers for trans young people, what they really mean is that there is a wealth of evidence, but that it is not the kind of evidence favoured by the GRADE system. But as Dr Gordon Guyatt, inventor of the GRADE system, said recently, using GRADE to justify bans of GAMT is “a clear violation of the principles of evidence-based shared decision-making.” After all, evidence-based medicine (also invented by Guyatt) recognises three pillars of strong treatment recommendations: (1) individual clinical expertise, (2) the patient's preferences and values, and (3) the best available clinical evidence. This is how the majority of medical treatments available are also supported by "low certainty" evidence, because doctors and patients recognise they are effective.

There is consensus among actual specialists treating trans patients that puberty blockers work and are safe.

Some people claim puberty blockers are dangerous

Like all medications, puberty blockers have potential side-effects, but none of these are life-threatening or even very life-changing.

The main claims made against puberty blockers are:

They reduce bone-density. This risk has been well-known for decades, and prescribing physicians in Australia scan for bone density regularly. For most young people, bone density increases after pubertal suppression is ceased and ultimately returns to normal levels. It’s true that we lack long-term studies on the topic, but in the absence of any complaints from patients it is irresponsible to ban care “just in case”. Interestingly, no-one is suggesting banning care for kids with precocious puberty, but they have bones too, right? The solution is careful monitoring and keeping young people on blockers as briefly as possible.
They affect cognitive development. There is very little evidence for this argument, but a recent study examining the association between IQ pre-treatment and educational achievement post-treatment in trans young people found that these were positively associated and comparable to the general population. In brief, no-one who has received treatment is complaining, and no-one appears to be concerned about cisgender young people receiving the same treatment.
They “lock in a trans identity”. This is pure fiction, or (if we’re being kind) speculation. The Cass Review promoted this theory based on the debunked 80% “desistance” myth, which claimed that 80% of trans young people would grow out of their trans identities if they did not receive GAMT. But that data stems from a time before the diagnosis of gender dysphoria existed. In those days (ie, the 1970s to early 2000s) “effeminate boys” made up most of the populations of child gender clinics and they could be diagnosed with “gender identity disorder” (the diagnosis used at the time) simply for having female friends, playing with so-called girl’s toys, or being “too close” to their mothers. To obtain that diagnosis, it was not necessary to identify as, or even to want to be, a gender other than the one they had been presumed to have at birth. To make matters worse, some of the studies cited to support the “desistance” theory took place in clinics that openly promoted conversion practices. Such practices have been shown to cause lifelong trauma and force people “into the closet” for several years. This means that even if some of the participants in those studies were trans, they may not have “grown out of it” but decided to hide their identities for fear of further trauma.

Some people claim puberty blockers are “experimental”

The term off-label does not imply an illegal, contraindicated or experimental use.

As we said above, puberty blockers have been used to treat cis young people with precocious puberty since the 1970s and trans young people since the 1980s, with no reports of widespread or serious harm. Nonetheless, because puberty blockers are considered to be “off label” when used to treat trans young people, some people claim they are untested.

But as the bioethicist Dr Simona Girodano says:

“‘Off-label use’ is the use of a drug for an indication that is different from the one for which it is licensed.

“Off-label prescription is both common and necessary in paediatrics, because many drugs have only been tested on adults as part of the development process leading to licensing and are therefore only licensed for use in an adult population.

“It is not primarily the lack of research that prevents the licensing of GnRHa for puberty delay in adolescents with gender dysphoria. It is likely that GnRHa could be licensed based on already existing research, but no one has an incentive to use the necessary resources to submit a license application.”

In summary

Puberty blockers are safe, reversible, have been used for decades, and go unchallenged when prescribed to cisgender children for precocious puberty.
There is evidence of potential reductions in bone density for some patients, but in most cases this returns to normal after treatment has ceased and there is no record of widespread serious harms.
Reports of “low certainty” evidence refer to a scientific term specific to the GRADE system and reflect both the impossibility of conducting randomised controlled trials for this group and the tiny numbers of young people accessing treatment. Many treatments that we, and especially young people, access regularly are supported by similar evidence.
The current bans on puberty blockers for trans young people are ideological, because they hold this treatment to a higher standard than other forms of healthcare. When combined with gender-affirming hormone treatment, puberty blockers help trans young people survive and flourish.