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:
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.