Updated 2026: Off-label use, a lack of evidence, and few safeguards for vulnerable children
Many gender clinics offer puberty blockers on the first visit
Reports of children who experience gender dysphoria, and seek medical attention for it, have grown exponentially across the western world over the last five to 10 years. As a result, it is safe to assume that thousands of children in the U.S., the U.K. – and Canada – are currently taking puberty blockers.
Many gender clinics have adopted the policy of offering puberty blockers or even cross-sex hormones (testosterone or estrogen) at a first visit. This is in line with the move to eliminate the need for mental health assessments.
Recent research by the Trans Youth Can team found that puberty blockers and other hormones are being offered to children at the first visit to a gender clinic in 62% of cases.
We’ve had readers reach out to ask: can this really be true in Canada? Some have insisted that either Canada’s healthcare system is too slow, or would treat this issue with more caution. Unfortunately, neither is true. For example, Radio-Canada wanted to see how quickly a 14-year-old girl (working undercover) would be able to obtain a testosterone prescription. It took her less than 10 minutes.
Radio-Canada “Are puberty blockers prescribed too quickly to young people”
And here is an account published on CGR from a parent of a now desisted teenaged girl who was offered puberty blockers at her first appointment at the Sick Kids gender clinic.
Planned Parenthood Toronto is one example of an organization that provides easy access to puberty blockers and hormones. It describes itself as a “100% gender-affirming space” and promotes ‘gender dysphoria assessment, diagnoses, and treatment” among its services because it is “here to support folks in accessing the care they need”.
Trans Youth Can notes that of the study participants not prescribed hormones on the first visit, the most common reason noted by physicians was simply “clinic protocol of not prescribing at first visit.” (emphasis ours). Another reason given here includes “fear of needles”.
The study is focused on youth who have been referred to gender clinics for hormones. Getting a referral is not difficult; one can easily be obtained from a family physician.
Learn about new gender policy changes coming to Alberta
Puberty blockers are not approved for treating gender dysphoria in minors
Puberty blockers are medications that temporarily halt the physical changes of puberty by blocking the body’s sex hormones, such as testosterone and estrogen. They work by disrupting hormonal signals from the brain to the ovaries or testicles.
While puberty blocking drugs such as Lupron have been approved and used for precocious puberty, they have never been approved for treating gender dysphoria in children at a normal age of sexual development, and for a much longer period of time.
The usage of puberty blockers for gender dysphoria is “off-label”, meaning that physicians prescribe them based on a hope that they can be effective and that the risks will not outweigh the benefits. Unfortunately, there have been no good quality studies of the effects of this treatment.
It is highly unlikely that Canadian clinicians are systematically collecting data on the effects of these medications.
From puberty blockers to cross-sex hormones
Advocates claim that puberty blockers are reversible. Stop taking them and puberty simply takes its natural course, they say.
The reversibility claims were made based on the usage of puberty blockers to halt precocious puberty – puberty in children as young as 8 years old. In these cases, gender dysphoria is not a factor.
What has been found is that when used as part of so-called gender-affirming care, the vast majority of children who begin treatment with puberty blockers move on to cross-sex hormones. In the UK, the finding from clinical data was that over 95% of children treated with puberty blockers also subsequently received cross-sex hormones.
The strength of this relationship is extremely unusual for medical practice. As a result, it is difficult to pull apart the effects of puberty blockers from hormonal treatment, which have irreversible effects.
Most clinicians now acknowledge that puberty blockers are not reversible and many believe that being put on a puberty blocker concretizes a trans identity, putting young people on a life-long medical pathway.
This stands in stark contrast to the previous “watchful waiting” model in which children were given time and space to mature, the vast majority (68-98%) had their gender dysphoria resolve and they aligned with their biological sex by early adulthood, with most growing up to be lesbian or gay.
Clinicians who use puberty blockers as a first line of treatment (as most do in Canada today) are promoting a belief to their young patients that they are doing something that is good for them. There is a significant amount of trust among Canadians that our medical professionals would only offer or recommend such invasive treatments if they were sure they were in a young person’s best interest. There are growing signs, however, that this trust may be misplaced.
What are the known side effects of puberty blockers?
Aside from the fact that the vast majority of children on puberty blockers go on to take cross-sex hormones, there is clear evidence that puberty blockers may harm bone development, may permanently alter the brain, and it is not yet known how they affect other vital organs, all of which undergo significant changes during uninterrupted puberty. Other known side effects include:
- Infertility
- Anorgasmia
- Mental illness (depression, suicidality, aggression)
- Osteopenia/osteoporosis
- Poor bone growth/short stature
- Chronic pain
- Potential negative effects on brain development
- Lack of penile length/scrotal tissue for future vaginoplasty
The British Journal of Medicine published an excellent summary of the current state of research in this area. The weak evidence, the article states: “doesn’t just mean something esoteric about study design, it means there’s uncertainty about whether the long term benefits outweigh the harms”.
The Society for Evidence-based Gender Medicine states that “While puberty blockers used to halt early (precocious) puberty have been shown to be reversible, no such studies exist for puberty blockers administered to stop normally timed puberty.”
The U.K. Cass said in its interim report: “it is important that it is not assumed that outcomes for, and side effects in, children treated for precocious puberty will necessarily be the same in children or young people with gender dysphoria.
The UK’s National Health Service has updated its guidance, removing statements about the reversibility of puberty blockers. Instead, the NHS now says: “Little is known about the long-term side effects of hormone or puberty blockers in children with gender dysphoria.” and “it is not known what the psychological effects may be”.
History of usage in Canada
Usage of puberty blockers in Canada began in 2005. The CAMH GIDS clinic in Toronto was the first clinic to introduce them, under strict cautionary principles and after much assessment and reflection with their young clients to try to determine whether they would be in a young person’s long-term best interest. Parents were an integral part of this decision-making process.
The founder of the CAMH GIDS clinic, Dr Susan Bradley, told CGR in an interview that the Canadian clinic started using puberty blockers with children who had a long history of gender dysphoria. A young person needed to be at least 16 years old. She said that the clinicians really had nothing but a “gut feeling” to go on and that they had adopted the usage of puberty blockers based on the Dutch protocol, which presented puberty blockers as reversible.
The American Academy of Pediatrics and the Endocrine Society endorsed this protocol on the belief that these kids were suicidal and that these interventions were life-saving. At the time, they also believed that puberty blockers were a “pause button” and fully reversible.
Soon after, medical societies started to produce guidance for the usage of puberty blockers based on the initial Dutch study of 55 young people (this cohort all presented with persistent and consistent early-onset childhood gender dysphoria, unlike many young people seeking gender transition today).
A lack of protection for vulnerable children
Clinicians within Canadian children’s hospital gender clinics have been quoted in the media saying that “comprehensive assessments” are done before children are started on invasive medical treatments, but that is clearly not the case if puberty blockers are often being initiated at the first visit. The London Gender Pathways Service even created a “consent” form for family physicians to use to initiate puberty blockers BEFORE a first visit to the gender clinic.
A typical assessment today includes a checklist of questions about medical history. However, clinicians are not given direction about what to do with the information gathered on the checklist. If, for example, a child is autistic, there are no standardized pathways or assessments to determine whether this child has adopted rigid thinking about gender while there are other factors at play.
Youth on the ASD spectrum typically have difficulty with self-regulation and don’t feel like they fit in, which can lead to depression, anxiety or suicidal thoughts. When such a youth, latches on to the idea that their distress is because they are transgender, their black-and-white thinking makes it very difficult for them to think more abstractly about sex and gender. Unfortunately, when gender becomes a focal point, all else is ignored, not only by the youth, but also by affirming school staff, therapists and physicians.
Canadian autistic children are being put on puberty blockers, cross-sex hormones and have undergone surgeries without being provided appropriate support to understand and manage their mental health issues (and explore how their gender-related distress may be entangled with these other issues).
This is also the case for young people who are gay and may be having difficulty understanding or accepting their sexual orientation, those who have suffered a history of trauma such as a sexual assault and for an unexplained and disproportionate number of children living in foster care and identifying as First Nations.
It’s clear that vulnerable children are not being protected from harm. There seems to be a growing belief system that medical gender transition is simply a reversible “gender journey” (to use a term written to us by Sick Kids Hospital).
CGR argues that it is overly simplistic – to the point of recklessness – to think of treatments that can have permanent changes on a young person’s physical, cognitive and emotional health as a gender journey.