NYT questions the safety of puberty blockers

November 15, 2022 • 9:30 am

I was surprised to see any article in the New York Times questioning current medical treatment for becoming transsexual, but this article does. And it’s written by two investigative reporters who actually read the scientific literature on puberty blockers. In fact, the article ends, like a scientific paper, with a list of seven references from the literature on the effects of puberty blockers on bone mass. Bona fides first:

Megan Twohey is a prize-winning investigative reporter and a best-selling author who has focused much of her work on the treatment of women and children. @mega2e  Facebook

Christina Jewett covers the Food and Drug Administration. She is an award-winning investigative journalist and has a strong interest in how the work of the F.D.A. affects the people who use regulated products. @By_Cjewett

Click on the screenshot to read it at the paper itself, or see it archived here

I found the article pretty good for what it is, though a bit scattered, going back and forth between the medical effects of puberty blockers, the effects of transitioning on people’s well-being, and stories of “desisters” or “detransitioners” who went back to their birth sex.  There are a few lessons to learn here.

Puberty blockers are of unknown safety.  These are drugs given to adolescents or children at various stages of puberty to allow them to “pause” their puberty while they ponder whether they want to become transsexual. While there have been many claims that these drugs are perfectly safe and that any halting of puberty can be reversed if patients changes their minds (most don’t, but go on to full transitioning), studies show pretty convincingly that the drugs have a deleterious effect on bone density, though the effect is lessened if patients take the drug (Lupron is one example) in early rather than late puberty. The effects on bone density can be so severe that they can cause osteoporosis or permanent bone damage.

. . .there is emerging evidence of potential harm from using blockers, according to reviews of scientific papers and interviews with more than 50 doctors and academic experts around the world.

. . . A full accounting of blockers’ risk to bones is not possible. While the Endocrine Society recommends baseline bone scans and then repeat scans every one to two years for trans youths, WPATH and the American Academy of Pediatrics provide little guidance about whether to do so. Some doctors require regular scans and recommend calcium and exercise to help to protect bones; others do not. Because most treatment is provided outside of research studies, there’s little public documentation of outcomes.

But it’s increasingly clear that the drugs are associated with deficits in bone development. During the teen years, bone density typically surges by about 8 to 12 percent a year. The analysis commissioned by The Times examined seven studies from the Netherlands, Canada and England involving about 500 transgender teens from 1998 through 2021. Researchers observed that while on blockers, the teens did not gain any bone density, on average — and lost significant ground compared to their peers, according to the analysis by Farid Foroutan, an expert on health research methods at McMaster University in Canada.

The findings match what practitioners of the treatment have seen, including Dr. Catherine Gordon, a pediatric endocrinologist and bone researcher at Baylor College of Medicine in Houston. “When they lose bone density, they’re really getting behind,” said Dr. Gordon, who is leading a separate study on why the drugs have such an effect.

The authors give other anecdotal evidence of blocker damage, like this one:

A transgender adolescent in Sweden who took the drugs from age 11 to 14 with no bone scans until the last year of treatment developed osteoporosis and sustained a compression fracture in his spine, an X-ray showed in 2021, as reported earlier in a documentary on Swedish television.

“The patient now suffers from continued back pain,” medical records note, describing a “permanent disability” caused by the blockers.

The scant data we have to date suggests that the reduction of bone density accompanying the use of blockers, even if followed by hormone treatment, may not lead to full recovery of bone density and strengh. 

Many doctors treating trans patients believe they will recover that loss when they go off blockers. But two studies from the analysis that tracked trans patients’ bone strength while using blockers and through the first years of sex hormone treatment found that many do not fully rebound and lag behind their peers.

That could lead to heightened risk of debilitating fractures earlier than would be expected from normal aging — in their 50s instead of 60s — and more immediate harm for patients who start treatment with already weak bones, experts say.

“There’s going to be a price,” said Dr. Sundeep Khosla, who leads a bone research lab at the Mayo Clinic. “And the price is probably going to be some deficit in skeletal mass.”

There may be long-term effects of puberty blockers on other parts body (e.g., the brain) that, says the article, might not show up until “decades later”. The fact is that there is very little research on the medical effects of puberty blockers, which is why several European countries are using them solely on a clinical-trial basis (England is contemplating this). The lack of data explains why this article concentrates almost entirely on bone density. Only when we have more data on more traits will adolescents contemplating transitioning be able to make a fully informed decision.

That said, the bone-density issue, which can be ameliorated if you give blockers early in puberty or treat later with calcium and medicine for osteoporosis, is not sufficiently daunting that, at least according to some doctors, it should not lead transitioners to change their minds or to transition by direct hormone treatment without the “pause” of blockers. Still, we have to remember that there are no tests of the long-term effects of the blockers. That will take considerable time.  Research is in progress:

Long-awaited research funded by the National Institutes of Health could provide more guidance. In 2015, four prominent American gender clinics were awarded $7 million to examine the effects of blockers and hormone treatment on transgender youth. In explaining their study, the researchers pointed out that the United States had produced no data on the impact or safety of blockers, particularly among transgender patients under 12, leaving a “gap in evidence for this practice.” Seven years in, they have yet to report key outcomes of their work, but say the findings are coming soon.

Puberty blockers are not approved by the FDA for halting puberty and are used off label. And some companies don’t even want FDA approval, presumably because it may not come. 

My emphasis below:

There is no centralized tracking of blocker prescriptions in the United States. Komodo Health, a health technology company, compiled private and public insurance data for Reuters, showing a sharp increase in the number of children ages 6 to 17 diagnosed with gender dysphoria, from about 15,000 in 2017 to about 42,000 in 2021. During that time, 4,780 patients with that diagnosis were put on puberty blockers covered by insurance, the data shows, with new prescriptions growing each year. But the data does not capture the many cases in which insurance does not cover the drugs for that use, leaving families to pay out of pocket.

Some leading American practitioners asked AbbVie and Endo Pharmaceuticals, maker of another blocker, to seek F.D.A. approval for the drugs’ use among trans adolescents. The drugmakers would have to fund research for a patient population that made up just a small part of their market. But the physicians argued that regulatory approval could help establish the safety of the treatment and broaden insurance coverage of the drugs, which can cost tens of thousands of dollars a year. In the end, AbbVie and Endo said no. The companies declined to comment on the decision.

To me, this is odious. These companies are putting profits before patients. What company wouldn’t want to know whether the drugs they make are safe?

Most patients who take blockers continue on to hormone therapy, i.e. to fuller transitioning. And according to the article, in general those who complete transitioning are happy with their decision.

Like Ms. Chavira, most patients who take puberty blockers move on to hormones to transition, as many as 98 percent in British and Dutch studies. While many doctors see that as evidence that the right adolescents are getting the drugs, others worry that some young people are being swept into medical interventions too soon.

. . .The first trans patient treated with blockers, from age 13 to 18, moved on to testosterone, the male sex hormone. Halting female puberty had offered emotional relief and helped him look more masculine. As the Dutch clinicians prescribed blockers, followed by hormones, to a half-dozen other patients in those early years, the medical team found that their mental health and well-being improved.

“They were usually coming in very miserable, feeling like an outsider in school, depressed or anxious,” recalled Dr. Peggy Cohen-Kettenis, a retired psychologist at the clinic. “And then you start to do this treatment, and a few years later, you see them blossoming.”

The general take I have on this article is that most people who decide to become transsexual are happy with their decision, despite the potential dangers of puberty blockers (they likely don’t know the scientific effects on bone density, and of course we don’t know the full scientific effects on the rest of the body). Is an informed decision then possible? Well, we don’t have all the medical data to say “fully informed”, but the feeling of relief that many describe when they transition suggests that in the absence of long-term studies, they can do three things:

a. Get “nonaffirmative” care. Since a hefty percentage of those who feel they’re in the “wrong” body (but don’t take puberty blockers) wind up gay rather than becoming transsexual, this suggests that an objective therapist, not committed to transitioning, should work with the patient beforehand. After all, transitioning, besides making you sterile, may have unknown medical effects, and presumably children who become gay are no less happy than those who transition. 

b.  Do not take puberty blockers but go directly from a child or adolescent to hormone supplements that cause permanent changes in your body. This, however, gives the young person no time to contemplate changing their gender, and surely you have to be old enough to give informed consent (see below).

c. Wait until you’re finished with puberty to start transitioning. Although this may prolong gender dysphoria, it staves off any deleterious effects of puberty blockers and also gives you some additional age that is supposed to be correlated with wisdom. This is the solution I recommend, but one that not everyone is on board with.


42 thoughts on “NYT questions the safety of puberty blockers

  1. You can see the NYTimes ever so slowly attempting to correct its dreadful record on this subject…..remember all the activist driven articles with no counter arguments that it published for years.

    I also wonder if someone will write a book tracing how this discussion has evolved…including how people like Jesse Singal and Abigail Shrier and many others were hounded, threatened, non-personed and so on for voicing facts and opinions that ran counter what has been the activist concensus.

    Not only that, but what of the hospitals, universities who in the face of all this lying said nothing to correct the record.

  2. One possibility to why pharmaceutical companies might balk at conducting clinical trials on puberty blockers for this purpose is a subset of individuals believe this course of action is unethical. The companies might be hesitant to enter that type of ethical debate.

    1. It is almost certainly cost. Clinical trials like these would cost millions and if the pateint population which gains access to the therapies through approval is small, that cost may never be re-couped. And that’s not the way to do business.

        1. Neverthesless, I believe that is the likely motive. But “UNETHICAL”? I am not sure I agree. Or disagree. This is a murky ethical domain. I wonder why you think it is unethical, beyond a wish that everyone who can benefit from a proven(ish) therapy ought to have access to it (on that I can agree)?

          1. I don’t want to argue about this but I will respond once. It’s unethical because there may be harms from these drugs, and yet companies that stand to profit from their sale are opposed to testing their safety. I don’t understand why that’s unclear to you. The therapy is NOT “provenish”; the one thing it’s been tested on (bone density) shows harmful effects, and there may be others found down the line.

            1. Summary of problems with Clinical Trials
              1. Large scale distribution of drugs off-label without clinical trials is considered by some as unethical.
              2. Double-blind placebo controlled clinical trials (the gold standard) is also considered by some as unethical. For example, some trans activist claim that having a placebo control group would cause undue harm to people in the study and as a result these trials should not be conducted.
              3. As a result, most (possibility all) studies conducted to date have no placebo control group, thus limiting the trial’s validity.
              4. Sorry, but I have no idea how to solve this problem.

              1. Re 2: Down through the ages, many passionate advocates have resisted the idea of controlled trials of their pet therapy on the grounds that a placebo arm would be unethical. Many of these treatments have been debunked when RCTs were eventually done. (E.g., extracranial-intracranial bypass to prevent stroke.). The harm is that these trials become hard to do because patients will refuse to be randomized to a 50:50 chance of getting placebo and demand to be given widely available treatment outside the trial.

                I don’t know how to solve that problem, either.

            2. Dr MacMillan makes some salient points below and I won’t belabor this. I’ll only say that it is clear to me that a pharmaceutical company has an ethical obligation to make sure their products are safe and effective for their approved use . I do not think, however, that they are ethically obliged to shoulder the time, cost and risk for things for which the drug is not approved or which they do not intend to market.

              BTW, the comment “provenish” I made was tongue in cheek; meaning all safety and efficacy studies used to determine a therapy’s usefulness are provisional; larger study sizes may unmask unknown risks. I did NOT mean it to be specific to this issue but as a general one which all drugs face. I regret the confusion

        2. Under the law, a pharma must obtain national regulatory approval—the FDA in the United States—if it wants to advertise or promote a drug for a particular “indication”, to use the jargon. With FDA approval, granted after the company submits sufficient results from trials of efficacy and safety, it can list that indication in the package insert and on its advertising, along with warnings about safety and adverse effects that were highlighted in the FDA submission, plus any post-marketing information.

          Drugs being discussed here are not licensed to be promoted for gender dysphoria and the pharma may not promote them for that indication. There is nothing except professional standards of care to prevent doctors from prescribing them for an “off-label” use, though. Many drugs are so used every day, often with solid evidence that they work and are safe. But the pharma will seek licensing of the heretofore off-label use only if it sees a business case, e.g., it expects a big bump in sales if it can promote it for the new role. If it doesn’t, the doctors are responsible on their own for determining efficacy and safety. A pharma can’t be held legally liable (in general) for off-label use unless it illegally promoted it.

          There is no ethical obligation for a company to pay for a study of effectiveness or safety of a drug that it does not intent to market for that purpose, especially if the drug is available generically: the generic manufacturer would reap the profits of the innovative company’s investment.

          Where the ethical shadiness comes is if a company’s detailers make oral representation to doctors that their drugs are useful for the off-label purpose: “You know, we can’t say this in writing but it seems clear that our drug is useful for gender dysphoria and all your colleagues are using it. You don’t want to be odd man out and lose patients to them, do you?”

          There is nothing to stop a granting agency from funding a randomized controlled trial of these drugs to see if they really are more effective than placebo with acceptable safety. There is no business or ethical case why the drug company ought to.

          1. I basically agree. Why (assuming no nod-nod wink-wink in their marketing) should a company have to fund a RPCT to prove or disprove the safety of their product for a non-indicated use? They’ve already had to prove safety and efficacy for specific indication(s). Should the makers of Ivermectin have to study whether it’s ok for use in Covid-19? Should Amgen have done a clinical trial to see if it was safe for world-class endurance athletes to use EPO, which was developed to help patients with anemia from kidney failure or cancer chemo, and never promoted to help someone win the Tour de France? Or anything else a group of true believers want to use for whatever purpose? Let them create a protocol under FDA scrutiny, then fund and do the study themselves. IMO, their ethical responsibility is to say we recommend NOT using our drug for unapproved indications.

    2. Plus if the puberty blockers are used without FDA approval I expect that there will be a legal defence for the manufacturers against claims from dissatisfied users later. I understand that the USA is very litigious.

  3. It seems like some people are taking a deeper look at these issues after the UK and other countries have started pulling back on transitioning. Undoubtedly, quite a few folks just jumped on the bandwagon because it is part of the Progressive agenda, and are now having second (or first) thoughts. It beats me, though, how people can think that blocking puberty, one of the key developmental phases in humans, wouldn’t have deleterious effects, physically and mentally. Like a lot of the Progressive agenda, it looks at the surface and seeks to project an agreeable image without exploring deeper problems.

  4. Something that has been well established is that trans people including young people have a higher suicide risk than the general population.
    More works needs to done to see how affermative vs non-affirmative care impacts this risk.
    If, and there is evdience to suggest this, puberty suppression reduces suicde risks in trans young people then that needs to be factored in.

    1. There is no evidence that I’ve seen of actual figures for deaths from suicide being higher in transgender children not receiving puberty blockers, as opposed to self-reported suicide ideation.

      According to “Trends in suicide death risk in transgender people: results from the Amsterdam Cohort of Gender Dysphoria study (1972–2017)”, C. M. Wiepjes, M. den Heijer, […], and T. D. Steensma, Acta Psychiatrica Scandinavica 2020 Jun; 141(6): 486–491,
      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7317390/ :

      We observed no increase in suicide death risk over time and even a decrease in suicide death risk in trans women. However, the suicide risk in transgender people is higher than in the general population and seems to occur during every stage of transitioning. It is important to have specific attention for suicide risk in the counseling of this population and in providing suicide prevention programs. [Pg 3]

      1. Yes, a pertinent comment. There are no data that show that actual ‘transitioning’ reduces suicide risk. It might even increase it, we simply don’t know.
        I think it is important to distinguish long standing ‘gender dysphoria’ from ‘sudden onset gender dysphoria”. I think the latter is not really gender dysphoria, but plain dysphoria, a way to express psychological or even social distress. As Shrier pointed out, there are clear parallels to “anorexia nervosa”.
        That being said, I think that giving puberty blockers, the longterm effects of which appear to be far from harmless (as our host points out), but mostly unknown, is profoundly unconscionable. Unless involved in a serious clinical trial, I think medical practitioners fancifully prescribing them should be stricken from the roll. Nothing less.

    2. I think Jesse Singal has discussed this. Many people pondering transition have mental problems anyway, and Jesse has said (and I’ve looked at the data, too), that transitioning has no clear effect on suicide risk. The study that seemed to show that was flawed.

    3. There are I think several additional problems here when assessing suicide risk. The belief that children who aren’t recognized as their “true gender” and/or refused the hormones and surgery of transition will likely kill themselves is common knowledge regardless of its truth. It’s especially well-known by the dysphoric kids and teens themselves — which may make it hard to separate genuine suicide risks from the rhetoric of distressed young people consciously or unconsciously following the role they’re expected to play.

      “Would you rather have a live son or a dead daughter?” “Would you rather have a live daughter or a dead son?” Gender therapists often ask this question of parents reluctant to go through with puberty blockers and other physical interventions. It’s clear emotional blackmail, and there are reports of presumably trained mental health professionals saying it while the child is actually in the room.

      Puberty-blockers and other gender-related “health care” are often referred to as “life-saving,” as if it was a treatment for malignant cancer. Going through normal puberty isn’t a good analogy. Instead, This it’s assumed that kids who don’t get the puberty blockers they want will kill themselves. Regardless of whether it’s inaccurate or irresponsible, the phrase reveals that they’re apparently fine with allowing suicidal children & teens to make drastic life-altering permanent decisions while in the grip of their intense misery. Mental health professionals usually don’t advise doing that.

    4. Agree with Jerry: please read Jesse Singal’s analysis of this argument. Trans youth who turn up at gender clinics do have high rates of mental health problems especially depression compared to other youth not in clinics. “Being trans” without treatment may cause these mental health problems, and lots of gender clinicians assume that resolving gender dysphoria through medical treatment will resolve mental health problems including suicidality. But instead it may be that untreated mental health problems including depression & suicidality may cause gender dysphoria. If the latter then transitioning is not expected to do anything to improve a person’s mental health. Singal’s substack shows all of this.

      Also see this comment by Biggs on the 2022 Turban et al. paper. Biggs reanalyzed their data: he showed no improvement in mental health from taking puberty blockers, and the data showed *worse* mental health (including hospitalization for suicide) in males who took estrogen as part of “affirmative gender care”. Turban has never replied to this devastating critique, but it’s exactly what one would expect if mental health problems cause gender dysphoria (not the other way round) and it’s consistent with what endocrinologists know about psychological effects of estrogen and testosterone (T is a euphoric).


    5. trans people including young people have a higher suicide risk than the general population.

      And? Suicide is just as much of a body sovereignty issue as transsexualism and abortion. We should not be stigmatizing or discouraging any of the three.

      1. People who kill themselves often are in overwhelming distress and incapable of clear rational thinking or hope. To ignore suicide as the desperate act it often is and reframe it as nothing more than a “body sovereignty” issue is heartless and disgusting. Those who are suicidal need our compassion and help during what must be severe trials. What they don’t need is the politicizing of suicide as an act of personal freedom just so trans activists can shore up their very, very shaky ideology. How many have killed themselves because of divorce, bankruptcy, the loss of a spouse, loneliness, chronic pain? How dreadful to frame human tragedy as just another personal freedom choice. Appalling

  5. If most children who go down the path of puberty blockers continue on to full transition, is that proof that it was the correct decision? Perhaps it is also proof that once such decisions are made, it isn’t really a “pause” but a commitment. They get into the transition system, and are pulled along. What impact if any do puberty blockers have on the very emotional and intellectual development needed to make sound decisions?

    My position on pharmaceuticals in general is that all other avenues should be tried before taking drugs to solve a problem. Drugs so often have side effects, so their benefits should always be weighed against the negatives. Since that is my prejudice for my own health, naturally I cringe at the idea of doing what sounds like an experiment on a generation of children. My conservative view may be proved wrong; after all drugs have sometimes improved the quality of life for me and those I love when we needed them.

    Hearing about the psychological pain some of these children are in, it seems cruel to deny them drugs if it brings relief. On the other hand, if there prove to be long-term negative impacts on their health, that would be cruel also. I come down on the side of gathering as much evidence as possible and requiring people to wait until they are adults to take permanent steps. It sounds like puberty blockers are more of a permanent step than they have been presented to be.

    1. Well said, but remember that some of this “path” may well be due to social pressure from parents, doctors, therapists, and peers. This is the thesis that Abigail Shrier makes: that the path is laid out largely by others, and you’re more or less forced to tread it.

    2. My understanding is that it is actually going through puberty and coming out the other side that leads most (about 70%, IIRC) to desist from a trans identity. That’s why such a high percentage of those who are given puberty blockers then proceed onto cross-sex hormones, because they are denied the process that would naturally reconcile their gender identity problems.

      1. There isn’t a lot of data because activists tend to shut down studies, but James Cantor’s survey of existing research (http://www.sexologytoday.org/2016/01/do-trans-kids-stay-trans-when-they-grow_99.html) suggests anywhere from 60% to 90% of kids decide not to transition once they hit puberty, and largely turn out to be gay/lesbian. Along with the long-term (and still largely unknown) deleterious effects of puberty blockers and the question of whether children really can consent to the use of such drugs (since they have no idea of the long-term consequences), this should argue against giving children these drugs.

  6. It has always seemed absurd (and disgusting) to me for any medical practitioner to claim that medicines that affect the normal progression of such a crucial developmental stage of a young person’s life could be “perfectly safe”.

    Even Tylenol isn’t perfectly safe, for crying out loud, and “puberty blockers” are throwing a spanner into the words of a ridiculously complicated system. Changes in bone density and neurologic changes could be only the very BEGINNING of negative outcomes. As mentioned above, there could be negative outcomes that begin and or persist for decades, shortening lifespans, affecting quality of life, and potentially INCREASING the risk of suicide down the road (certainly if someone has chronic pain from compression fractures, they are going to be at increased risk of suicide). I wouldn’t be surprised if long term risks of various kinds of cancers could be changed, for better or worse. And we won’t know for decades at the earliest.

    Anyone who speaks with unwarranted (and unwarrantable) confidence about ANYTHING, let alone such a profoundly powerful and subtle intervention as altering the usual hormonal course of adolescence might as well be sounding a roaring claxon indicating that they are NOT to be trusted, and people should keep their distance. I’m VERY glad that more members of even the Woke are beginning to be more concerned about this. It’s just too easy to allow ideology to grind naïve, innocent lives into powder–or compressed, osteoporotic bone–with those doing the grinding excusing themselves with the get out of jail free card that their “intentions” are pure.

  7. One side effect to puberty blockers which the article doesn’t mention is the possibility of lower libido and inability to orgasm. If children go on blockers before they’ve experienced the sexual arousal fueled by adolescent hormones their brains and genitals don’t necessarily pick it up when cross-sex hormones are administered later on. In addition, a child-like penis is also too small to work well when constructing an artificial vagina.

    Jazz Jennings, a boy who was transitioned in front of the cameras for a long-running reality show about a “trans kid,” now suffers from those and other problems as the result of taking puberty blockers. Doctors who were filmed during the “bottom surgery” expressed dismay at the lack of material to work with and seemed to be making it up as they went. Jazz still doesn’t have orgasms or seem to have much of a sex drive, despite having had multiple surgeries to correct problems.

    1. Jennings also experienced deep depression and enormous weight gain. Whatever one thinks of childhood transitioning, Jennings is not a great advertisement for it.

      I think the glib dismissal of the likely sexual side effects of puberty blockers in adult life is absolutely appalling.

      Most pre-pubescent kids tend to be a bit “squicky” about sexuality, as we might expect (at least in a society where they receive that message). They literally cannot conceive of sex or its associated sensations, and therefore have nothing positive to go on.

      So there they are, age 11 or whatever, enthusiastically charging into a future that very likely will foreclose on much of the sexual pleasure they might have experienced as adults had they not begun to “transition” (into an approximation of the other sex, I will note) via puberty blockers.

      In a weird way, the whole “trans” movement is a back-door way into sexual puritanism and denialism. And, IMO, it’s also transparently anti-gay and anti-female.

      And here’s a hunch: absent social media, it would never occur to the vast majority of gender-discordant kids that the “problem” can be neatly, niftily “solved” through the wonders of literally lifelong, intrusive medical intervention.

  8. What company wouldn’t want to know whether the drugs they make are safe?

    The companies do know that their products are safe. For the purposes for which they have tested them. I have a cigarette lighter which is designed to safely light cigarettes sticking out of my face. If I choose to use it to light the fuse on a stick of dynamite, does that make the lighter unsafe?
    The ethical challenge for these off-label uses of the drugs lays with those who use their (typically state-certified) personal clinical judgement to prescribe them for uses that their manufacturers don’t recommend them, and haven’t (AFAIK) sought approval.
    FYI, the reported FDA approvals for the drug you name are :

    – for treatment of advanced prostate cancer, 1985
    – for palliative treatment of advanced prostate cancer, 1989
    – (different delivery form) for palliative treatment of advanced prostate cancer, 2000
    – (different delivery form) for palliative treatment of advanced prostate cancer, 2002
    – for children with central precocious puberty, 2020

    All those “palliative care” approvals tells me that the company knows exactly how “safe” it’s drugs are. And those physicians who prescribe them outside that palliative context are taking a lot of responsibility on their shoulders. The manufacturers are no more responsible for their use of these drugs than, say, electricity grid workers are for the prison officer who pulls the switch on “old sparky”.
    Yes, this does reflect back on the European companies who refuse to sell their drugs for use in state-sponsored murders. They are exercising precisely the sort of “responsibility for off-label uses” that you promote. And outraging another, not strongly overlapping, branch of society in the process.
    I also note that this drug (at least) is on the World Health Organization’s List of Essential Medicines. Presumably that’s for it’s on-label uses, not it’s off-label uses.

  9. I think transgender care is one of the most profound ethical issues of our time, and I think the root of transphobia (real transphobia, not the reflexive insults hurled at people like JK Rowling or Abigail Shreier) is an unwillingness to confront the difficult questions in a genuine manner. It’s much easier to believe that trans kids have a mental illness, or are simply victims of a social contagion, than it is to really grapple with the ethical balance that must be struck between the needs of trans individuals and the fact that the best results are achieved when people start their transition early.

    It’s fairly clear to me that early intervention with puberty blockers and hormone treatment offers the potential for trans people to transition more completely (from an outward presenting perspective), and can greatly improve social acceptance and consequent feelings of well-being. Those feelings of well-being may well outweigh a loss of bone density (or other long-term effects as yet unknown) for an individual. If you subscribe to a moral framework wherein the goal is to maximize human flourishing, then this is a moral approach to take.

    But it’s such a profound dilemma precisely because that decision needs to be taken at an age where the human brain’s decision-making facilities are not fully formed, the sense of self is in great flux, and opinions/ideas are far too easily swayed by peers, parents, authorities, etc.

    I don’t know how to weigh these. I don’t know what it’s like to feel like I don’t belong in my body, and I’m reluctant to tell trans-identifying kids that it’s just a phase, or just in their head. But I also can’t honestly recommend that pre- or pubescent kids make that decision. I think there has to be a process with extensive counseling, for sure, so I would rule out automatic gender affirmation.

    1. That’s a super thoughtful comment.

      But what does it mean to be trans? Because humans don’t have a gendered soul that’s separate from the body, being trans must be some kind of physical thing happening in the part of the body where feelings occur. And a brain can’t be born in the wrong body. To the extent that gender dysphoria prevents people from functioning, trans really is a mental illness or disability. Most of the trans people I know have obvious significant mental health problems, and those who don’t appear to have been swept up in a ROGD social group.

      How should we help these folks? It’s hard to see how stopping a normal and important developmental process (puberty), or medicating with hormones that would not normally be produced in quantity by that person (estrogen, testosterone), or surgically removing and reshaping healthy body parts are good solutions to those mental health problems. I think these solutions will soon be seen as 21st century lobotomy. Counselling and treatment for depression and autism, and for unresolved sexual orientation, seem way more humane.

      But like you I don’t really know what trans feels like, and I think adults should be able to do what they want with their bodies so long as they don’t harm others (for several definitions of “harm”). So I think no affirmation for kids (including no social transition, pronouns, or blockers), and cautious affirmation for adults. And I think we should support gender non-conforming people of all sorts who reject dumb stereotypes for women and men.

    2. It is true that a young male that takes puberty blockers and then goes on HRT is usually going to look and sound a lot more like a typical female than someone who goes through male puberty. But it also causes problems. For example, the penis doesn’t grow so there won’t be enough tissue for a vaginoplasty if they want that. And there is a very good chance they will never feel an orgasm. This information came from an article by a doctor who is getting concerned about the number of young transitions. The doctor also is transgender so negative bias is unlikely (unfortunately I don’t remember their name off hand).

      My current view is that puberty blockers should only be used as a last resort after extensive counseling to try to determine if it really is their best option and a strong effort to make the child and their parents aware of the risks and limitations of the procedure, telling them what the child likely will face in future years. My impression is that many have an unrealistic idea of what it will actually do, and are shocked when they later have to face reality. Of course, this type of counseling is often now attacked as attempting “conversion therapy” despite it being very different from the gay kid “conversion therapy” of the past. All too often, the kids apparently get “affirmative” therapy these days and not much of that.

  10. Here’s how I’d handle it. Simply say.

    “We do not know the future outcome of this treatment as it’s still so new, so the long term effects are not yet known. We’d like to be able to monitor you over the years to a level you are happy with in order to learn the long term effects so people in the future can make more informed decisions.

    Again, this is new, and you are taking this at your own free will as parents and we will not take responsibility of what happens outside of what we know in theory.”

    Seems fair to me.

  11. If we are to take seriously what Darwin said about morality in Chapter IV of his “The Descent of Man,” then its ultimate cause, the reason it exists to begin with, if you will, lies in behavioral predispositions that exist by virtue of natural selection. In other words, they exist because they happened to improve the odds that the bearers of the responsible genes would survive and reproduce. If that’s the case, then it’s hard to imagine anything more immoral than chemically and surgically impairing the ability of a child to ultimately have children of its own in order to “transgender” it.

    Prof. Coyne has been criticized by philosophers for allegedly not reading enough tomes of philosophy. Our current crop of academic philosophers has concocted scores if not hundreds of different flavors of morality. How many of them have come out strongly against “transgendering” children in this way based on whatever flavor they happen to prefer? I suspect that not a single one has dared to get out of step with his academic tribe. So much for the value of reading tomes of philosophy.

    I personally don’t believe in objective morality, but it does seem to me that this “transgendering” of children is somewhat out of harmony with the reason morality exists to begin with.

    -Doug Drake

  12. Why express suspicions about what philosophers have said about the ethical issues around gender transitions? Why not look? Not a single philosopher out of step with his academic tribe? There has been substantial division among philosophers, although it is true that some philosophers have not encouraged debate. Among philosophers there is an extremely thoughtful trans woman, a fine philosopher, Sophie Grace Chappell, who has been eager to go on talking about some of the most divisive issues. Two other philosophers have recent books which explore these divisive issues.

    1. I asked a simple question. Which academic philosopher has come down firmly against “transgendering” children? Obviously, that is not the same thing as “talking about” or “exploring” the issues. The question remains open. I have looked for myself, and I haven’t found a single one. As I mentioned above, I don’t believe in objective morality. However, for those who do, and who also accept what Darwin wrote about morality and Westermarck’s elaboration of it, it must follow that nothing can be more immoral than destroying a child’s ability to reproduce by “transgendering” it. This seems an obvious conclusion, yet none of the academic philosophers, in spite of their myriad versions of morality, seems to have noticed. Allow me to make a prediction. None of them ever will notice, because none of them dare to get out of step with their academic ingroup.

  13. Isn’t it interesting how quickly we have normalized talking about puberty blockers?

    Have we somehow completed the discussion about why are physically healthy kids being medicalized to the point that their normal development is being disrupted in such an important time as is puberty? Why are kids being placed on lifelong medicalization with so many adverse effects, and even worse, we do not even know all the adverse effects, have we completed that discussion? We are treating a condition that 30-40 years ago was a rare curiosity, but is now becoming so pervasive that we need to change our language to adapt to this new situation? We are no longer teaching kids ABCs, and multiplication table in school, but that being born in wrong body is something they should seriously consider and take steps, without the knowledge of their parents, to correct it? Rapists and other violent criminals are being kept in women’s prisons due to the idiocy of gender Self ID, women’s sports and other activities are being intruded upon and colonized by aggressive men who seem to use this as opportunity for voyeurism and exhibitionism.

    I have 4 teenage daughters, and on our last family trip while at LAX, we ended treating visit to women’s bathroom as Navy Seal operation. My youngest went by herself, only to run out 20 sec later because a ‘transwomen’ was making a video there and tried including my kid. So girls went one by one, with my wife, while I was waiting outside, so they are never by themselves while around bathroom…

    I am a child and adolescent psychiatrist, have been for 30 years. You worry about osteoporosis and brittle bones? That is going to be minor issue once we realize what is “puberty blockade” doing to their brains, their psychological, emotional and especially intellectual development…. US kids are lagging in psychological development, every year we send less and less mature kids to colleges or out to the world… Now we are stopping their development during puberty: what could possibly go wrong.

    As someone who has been reading studies my whole life, the studies on the subject of transitioning kids are criminally poorly done. The other day I was reading a study on how well transitioning works only to realize that the main investigator is fourth year medical student. The top authority in San Francisco on psychiatry of transitioning kids had just completed fellowship, but is widely published in Psychology Online, Scientific American, Teen Vogue and similar ideological pseudoscientific magazines….

    Another thing regarding studies, is that these days you can publish a bad study disproving what is self evident, and that becomes scientific truth … Some examples are sex spectrum (nope, it is not), suicides amongst trans kids (why are there no reports of kids killing themselves because nobody was affirming their “gender identity” 20 years ago?), men can compete against women in women’s sports fairly, after a year of ‘testosterone supression (forget what you know, we have a study)….

    So, once again: have we accepted necessity of puberty blockers for physically healthy but confused kids, and moved onto discussing their adverse effects?


  14. The whole concept of childhood transitioning is disturbing. Why would any adult want to induce/facilitate a permanent physical change in someone who is still developing?

    I believe that no hormonal (including blockers) or surgical affirmative treatment should be condoned until age 26, and only after several years of therapy. At the least, it is a relief that more people are recognizing that the blockers are not fully reversible and are not a ‘pause’ but are an alternative with ongoing effects.

    I know that some people still believe that child who are not allowed to transition have a higher incidence of suicide, however that claim resulted from a false comparison of children with gender dysphoria to the general population of others their age. When these children are compared to others their age suffering from similar levels of anxiety, depression, trauma, etc. the increased incidence of suicide is not present.

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