Puberty blockers impair genital development and may complicate later surgical outcomes

Suppressing puberty alters normal genital and bodily development, which may affect later surgical options and outcomes. Reviews of the evidence have raised concerns that reduced genital tissue development following puberty suppression can limit surgical options – for example, by making standard penile inversion vaginoplasty impossible – and increase the complexity of later genital surgeries.

Prominent examples include:

• In the seminal Dutch cohort (de Vries et al., 2014), an 18-year-old patient died from necrotizing fasciitis and sepsis following intestinal (sigmoid) vaginoplasty. Due to early puberty suppression, there was insufficient penile tissue for the standard surgical technique, necessitating the use of a higher-risk bowel segment procedure.
  
• Jazz Jennings, star of the reality TV series I Am Jazz, began puberty blockers at age 11. This resulted in insufficient penile tissue development, requiring a more complex vaginoplasty using additional tissue sources, including peritoneal tissue and skin grafts. Jennings later experienced severe post-operative complications, including wound separation and splitting of the neovagina, necessitating multiple revision surgeries (TLC, 2018). Jennings also gained substantial weight – nearly 100 pounds (~45 kg) – after starting puberty blockers and cross-sex hormones, at one point reaching morbid obesity (over 200 lbs / 90 kg), which further complicated surgical preparation and recovery (TLC, 2022).

Observational studies have also reported changes in growth, bone development, and BMI during and after treatment with puberty blockers, although the available evidence remains limited and methodologically weak. Long-term outcomes remain insufficiently studied (Taylor et al., 2024).

^{de Vries, A. L. C., McGuire, J. K., Steensma, T. D., Wagenaar, E. C., Doreleijers, T. A. H., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696-704. https://doi.org/10.1542/peds.2013-2958} 

^{Taylor, J., Mitchell, A., Hall, R., Heathcote, C., Langton, T., Fraser, L., & Hewitt, C. E. (2024). Interventions to suppress puberty in adolescents experiencing gender dysphoria or incongruence: A systematic review. Archives of Disease in Childhood, 109(Suppl 2), s33-s40. https://doi.org/10.1136/archdischild-2023-326669}

^{TLC. (2018, September 8). Jazz experiences complications post surgery | I am Jazz [Video]. YouTube. https://www.youtube.com/watch?v=rU-uzjzNCVc}

^{TLC. (2022, January 25). Jazz is heartbroken by her weight gain | I Am Jazz [Video]. YouTube. https://www.youtube.com/watch?v=MSv3vq6L-fA}

^{University of California San Francisco, Gender Affirming Health Program. (2016, June 17). Vaginoplasty procedures, complications and aftercare. UCSF Transgender Care. https://transcare.ucsf.edu/guidelines/vaginoplasty}

^{Zepf, F.D. et al. (2024). Beyond NICE: Aktualisierte systematische Übersicht zur Evidenzlage der Pubertätsblockade und Hormongabe bei Minderjährigen mit Geschlechtsdysphorie. Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie, 1-21. DOI: 10.1024/1422-4917/a000972
PDF: Full paper PDF}