And with this decision, implemented on Friday (see NHS announcement below), the UK joins several other European countries—Finland, Norway, and Sweden—in removing adolescents’ access to puberty-blocking hormones except in clinical trials. This is clearly a significant decision given the UK’s previous reassurances, in the Tavistock Gender Centre, that puberty blockers were perfectly safe and reversible.
And this reassurance is still given all over America, too, conveyed to adolescents contemplating “stalling” puberty until they decide what to do. (Most decide to continue with the transition, going on to full male or female hormone treatment and/or opting fur surgery.)
But such assurances of safety and reversibility are not credible right now, for we just don’t have enough data to deem puberty blockers (used off label) as either “safe” or “completely reversible”. In fact, there are suggestions of some possible physical harms, harms that the NYT wrote about in both January and November of last year. We won’t know for sure until proper clinical trials are done. Until then, it’s irresponsible to prescribe these drugs outside of a trial. And of course proper warnings and written assent of patients that they understand the warnings are essential.
Here’s what else is irresponsible: writing an article about possible harms of puberty blockers but mentioning only psychological harms, neglecting the physical ones. Click below to see the NYT’s new article about this (and at least they covered it); I also found it archived here.
After in the article above, the NYT adds this about possible “harms” (they do say that the NHS “stated that ‘there is not enough evidence to support their safety or clinical effectiveness as a routinely available treatment’.”)
Background: Data on the effects of blockers is sparse
Last year, the N.H.S. announced that it would be shutting down the country’s only youth gender clinic after an external review showed that the Tavistock Gender Identity Development Service had been unable to provide appropriate care for the rapidly increasing number of adolescents seeking gender treatments. The clinic had seen a sharp rise in referrals, from 250 young people in 2011 to 5,000 in 2021.
Puberty blockers, which work by suppressing estrogen and testosterone, were first tested on children with gender dysphoria in the Netherlands in the 1990s. The Dutch researchers published their first study on 70 children in 2011, finding that the adolescents reported a decrease in depression and anxiety after taking the drugs.
But a British study of Tavistock patients published in 2021 showed that blockers had no effect on children’s scores on psychological tests. The study found that 43 out of the 44 participants later chose to start testosterone or estrogen treatments. One interpretation of the data is that all were good candidates for hormone therapy. But the numbers raised concerns at the N.H.S. about whether the drugs served their intended purpose of giving adolescents time to think.
“The most difficult question is whether puberty blockers do indeed provide valuable time for children and young people to consider their options, or whether they effectively ‘lock in’ children and young people to a treatment pathway,” Dr. Hilary Cass, the pediatrician overseeing the independent review of the N.H.S. gender service, wrote last year.
Note the absence of any mention that there’s more than psychological harm at stake, and the lack of any report that long-term physical harm hasn’t been properly studied.
But see this from the NYT article in January of last year:
Few studies have followed adolescents receiving puberty blockers or hormones into adulthood. Dr. Ehrensaft and others are now working on large, long-term studies of patients in the United States.
. . . Puberty blockers, for example, can impede bone development, though evidence so far suggests it resumes once puberty is initiated. And if taken in the early phase of puberty, blockers and hormones lead to fertility loss. Patients and their families should be counseled about these risks, the standards say, and if preserving fertility is a priority, drugs should be delayed until a more advanced stage of puberty.
. . .Experts in transgender health are divided on these adolescent recommendations, reflecting a fraught debate over how to weigh conflicting risks for young people, who typically can’t give full legal consent until they are 18 and who may be in emotional distress or more vulnerable to peer influence than adults are.
Here the article appear sto be talking about post-blocker treatment with male or female sex hormones.
Some of the drug regimens bring long-term risks, such as irreversible fertility loss. And in some cases, thought to be quite rare, transgender people later “detransition” to the gender they were assigned at birth. Given these risks, as well as the increasing number of adolescents seeking these treatments, some clinicians say that teens need more psychological assessment than adults do.
And here’s what the NYT said last November:
Dutch doctors first offered puberty blockers to transgender adolescents three decades ago, typically following up with hormone treatment to help patients transition. Since then, the practice has spread to other countries, with varying protocols, little documentation of outcomes and no government approval of the drugs for that use, including by the U.S. Food and Drug Administration.
But 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.
The drugs suppress estrogen and testosterone, hormones that help develop the reproductive system but also affect the bones, the brain and other parts of the body.
During puberty, bone mass typically surges, determining a lifetime of bone health. When adolescents are using blockers, bone density growth flatlines, on average, according to an analysis commissioned by The Times of observational studies examining the effects.
. . .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.”
So why didn’t the NYT emphasize, in its latest article, that some doctors think there are long-term physical harms that may come from blockers? That was, after all, one of the reasons why the NHS and other nations in Europe have limited their use to clinical studies. I can guess only that they don’t want to get into the messy (but necessary) details.
The NHS announced the policy taking effect in a curiously anodyne statement on “Implementing advice from the Cass Review“, referring to a scathing indictment of the Tavistock clinic by Hilary Cass, former President of the Royal College of Paediatrics and Child Health). Here’s the bit about blockers, with a link to more on another site:
We are now going out to targeted stakeholder testing on an interim clinical commissioning policy proposing that, outside of a research setting, puberty suppressing hormones should not be routinely commissioned for children and adolescents who have gender incongruence/dysphoria.
The purpose of the clinical policy is to formalise this commissioning approach and ensure there is clarity on the position by the time the new service providers begin seeing patients in the context of the new and final interim service specification. The interim service specification and the clinical policy, once finalised, come together to define the overall commissioned service.
NHS England has established a new national Children and Young People’s Gender Dysphoria Research Oversight Board which has now approved the development of a study into the impact of puberty suppressing hormones (‘puberty blockers’) on gender dysphoria in children and young people with early-onset gender dysphoria. More information on the Board and the study can be found in the consultation report.
The U.S. really should take these other countries’ decisions more seriously. Indeed, puberty blockers have been banned in ten U.S. states, along with a general ban on “gender-affirming care.” Those states are all Republican, and so the Democrats and gender activists have become enraged, deeming these laws “transphobic”. And indeed, perhaps an animus against trans people has motivated some of the laws’ stipulations, but I’m talking only about the bans on puberty blockers. Until we know more about them, it seems wise to do the clinical studies. Yes, it’s possible and even likely that the blockers won’t erode mental health, and may even improve it in gender-dysphoric children, but mental health is not the only issue at stake.
Further, since about 70% of children diagnosed with gender dysphoria eventually grow out of it without hormone treatment, often becoming lesbian or gay, it also seems that we should hold off on these blockers and replace them with empathic (not “affirmative”) therapy. Given the high incidence of resolution without blockers, the possible medical damage, the lack of long-term studies, the fact that most children on blockers go on to full transition, taking sex hormones and sometimes getting surgery (a course that renders them infertile and often unable to achieve orgasms), and the unlikelihood of children as young as 10 or 11, when puberty begins, being able to make informed and irreversible medical decisions—all this makes me think that the U.S. should follow the lead of Europe: use blockers only in clinical trials until they’re proven to be safe (or unsafe).
That is not, of course, to say that children with gender dysphoria shouldn’t be treated. What they need until the age of consent for transition (I tend to favor 18, but your mileage may very) is good psychological therapy, not therapy in which the doctor eggs on children to take blockers and then become transsexual. Good therapy is not just one or a few sessions with an explicit goal of transitioning, but listening to children and helping them work out their issues. If, at the age of consent, they still want to transition, by all means allow them to do so and support them.
The NYT seems to have a curious attitude toward puberty blockers. First it takes two steps forward, calling out their dangers, and then takes one step back, hiding their dangers.
UPDATE: For a stronger negative view of puberty blockers, see this WSJ op-ed.