Category: Iatrogenic harm
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Puberty blockers disrupt the normal timing of puberty relative to same-age peers, with associated psychosocial effects
A 2024 systematic review noted that puberty blockers disrupt the normal timing of pubertal development relative to same-age peers. Puberty is an important developmental phase associated with identity formation, body image, emotional development, and peer integration.
Broader adolescent research has associated variations in pubertal timing with psychosocial outcomes including mood difficulties, social challenges, and depressive symptoms.
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 -
The combination of puberty blockers followed by cross-sex hormones leads to permanent loss of fertility
A 2024 systematic review notes that puberty suppression alone does not necessarily eliminate future fertility, as endogenous puberty may resume after treatment stops. However, when puberty blockers are followed by cross-sex hormones, fertility potential may be significantly impaired or permanently lost, particularly if fertility preservation has not occurred beforehand. This review therefore highlights that fertility risks emerge through the sequential treatment pathway from puberty suppression to cross-sex hormones.
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 -
A 2024 systematic review found that 39% of female participants were overweight before starting puberty blockers. During treatment, BMI increased further, particularly among females, alongside disruptions to expected growth patterns.
A 2024 systematic review reported that 39% of biologically female participants were classified as overweight prior to beginning puberty blockers. During treatment, increases in BMI-SDS were observed, particularly among biologically female participants, alongside alterations in expected growth trajectories.
The review noted that the available evidence remains limited by small sample sizes, heterogeneity between studies, and the observational nature of the data.
Jazz Jennings, star of the reality TV series I Am Jazz, began puberty blockers at age 11. Jennings gained substantial weight (nearly 100 pounds / ~45 kg) after starting blockers and cross-sex hormones, reaching morbid obesity (over 200 lbs / 90+ kg) at one point, which further complicated surgical preparation and recovery. (TLC, 2022).
TLC. (2022, January 25). Jazz is heartbroken by her weight gain | I Am Jazz [Video]. YouTube. https://www.youtube.com/watch?v=MSv3vq6L-fA
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 -
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 - 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.
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Fertility preservation creates an iatrogenic tension between protecting future fertility and imposing immediate psychological burden
Fertility preservation is often recommended before cross-sex hormones because these treatments may impair future fertility. However, studies report that the procedures required for egg or sperm retrieval are frequently experienced by adolescents and young adults with gender dysphoria as psychologically distressing, physically invasive, or emotionally intolerable. As a result, many decline fertility preservation altogether. This creates an iatrogenic tension in which a medical intervention intended to protect future reproductive autonomy may itself become a source of distress and reduced decision-making capacity.
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 -
94% of females taking testosterone experience pelvic floor dysfunction.
In a study1 of 68 women taking testosterone, 94.1% had some form of pelvic floor dysfunction. 86.7% had urinary symptoms. Other problems included storage symptoms (69.1%), sexual dysfunction (52.9%), anorectal symptoms (45.6%), and flatal incontinence (39.7%.)
- da Silva LMB, Freire SND, Moretti E, Barbosa L. Pelvic Floor Dysfunction in Transgender Men on Gender-affirming Hormone Therapy: A Descriptive Cross-sectional Study. International Urogynecology Journal. 2024 May;35(5):1077-1084. doi: 10.1007/s00192-024-05779-3. Epub 2024 Apr 25. PMID: 38662108. ↩︎