Category: Puberty blockers • Page 2
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Puberty blockers and cross-sex hormones negatively impact bone health in a significant number of cases
There is little long-term evidence on bone mass density in relation to puberty blockers. However, in a significant minority of cases of long-term puberty suppression related to gender identity, bone mass density scores qualify as “low for age”1. Low bone mass density increases risk of osteoporosis and fractures.
Adolescents who enter puberty at an older age have persistently lower bone mass density than their peers2: in one case study3, an adolescent had a bone mass density -2 standard deviations below the mean after three years of blocking puberty.
It has also been noted4 that:
In early-pubertal transgender youth, BMD [bone mass density] was lower than reference standards for sex designated at birth. This lower BMD may be explained, in part, by suboptimal calcium intake and decreased physical activity–potential targets for intervention.
Bone metabolism is also decreased as a result of taking cross-sex hormones, for both males and (in later life) females5.
- Biggs, M. (2021). Revisiting the effect of GnRH analogue treatment on bone mineral density in young adolescents with gender dysphoria. Journal of Pediatric Endocrinology and Metabolism 34 (7): 937-939. [Link] ↩︎
- Elhakeem, A., Frysz, M., Tilling, K., Tobias, J.H. & Lawlor, D.A. (2019). Association Between Age at Puberty and Bone Accrual From 10 to 25 Years of Age. JAMA Netw Open; 2(8). [Link] ↩︎
- Pang, K.C., Notini, L., McDougall, R., Gillam, L., Savulescu, J., Wilkinson, D., Clark, B.A., Olson-Kennedy, J., Telfer, M.M. & Lantos, J.D. (2020). Long-term Puberty Suppression for a Nonbinary Teenager. Pediatrics 145 (2). [Link] ↩︎
- Lee, J. Y., Finlayson, C., Olson-Kennedy, J., Garofalo, R., Chan, Y. M., Glidden, D. V., & Rosenthal, S. M. (2020). Low Bone Mineral Density in Early Pubertal Transgender/Gender Diverse Youth: Findings From the Trans Youth Care Study. Journal of the Endocrine Society 4 (9). [Link] ↩︎
- Vlot, M.C., Wiepjes, C.M., de Jongh, R.T., T’Sjoen, G., Heijboer, A.C. & den Heijer, M. (2019). Gender-Affirming Hormone Treatment Decreases Bone Turnover in Transwomen and Older Transmen. J Bone Miner Res, 34: 1862-1872. [Link] ↩︎
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There is little evidence that medical transition decreases suicidality
When it comes to gender dysphoric children, there is little evidence that medical transition decreases suicide rates. There is little evidence to assert that puberty blockers are necessary to prevent suicide1.
After sex reassignment surgery, one study showed that adult transsexual clients were 4.9 times more likely to have made a suicide attempt and 19.1 times more likely to have died from suicide, after adjusting for prior psychiatric comorbidity2. Similarly, an Australian paper3 notes that many patients have poor outcomes, which puts them at risk of suicide.
A prominent study4 claiming that medical transition alleviated suicidality had to be corrected5, to clarify that it proved “no advantage of surgery” in this regard.
A long-term Swedish study6 finds that post-operative transgender people have “considerably higher risks” for suicidal behavior.
Similarly, a study in the European Journal of Endocrinology7 demonstrates that suicide rates among transgender male-to-females were 51% higher than the general population.
- Biggs, M. (2020). Puberty Blockers and Suicidality in Adolescents Suffering from Gender Dysphoria. Archives of Sexual Behavior (49): 2227–2229. [Link] ↩︎
- Zucker, K.J., Lawrence, A.A., Kreukels, B.P. (2016). Gender Dysphoria in Adults. Annu Rev Clin Psychol. 12: 217-47. [Link] ↩︎
- D’Angelo, R. (2018). Psychiatry’s ethical involvement in gender-affirming care. Australasian Psychiatry 26 (5): 460-463. [Link] ↩︎
- Bränström, R. & Pachankis, J. E. (2019). Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study. American Journal of Psychiatry 177 (8): 727-734. [Link] ↩︎
- American Journal of Psychiatry (2020). Correction to Bränström and Pachankis. Published online: 1 August 2020. [Link] ↩︎
- Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. L. V., Långström, N., & Landén, M. (2011). ‘Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study in Sweden’. PLoS ONE, 6(2). [Link] ↩︎
- Asscheman, H., Giltay, E. J., Megens, J. A. J., de Ronde, W., van Trotsenburg, M. A. A. & Gooren, L. J. G. (2011). A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. European Journal of Endocrinology 164 (4). [Link] ↩︎
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There is limited evidence that medical transition leads to positive outcomes
A number of different studies have noted the paucity of good quality evidence for transition.
An Australian paper1 states that most available evidence indicating positive outcomes for gender reassignment is of poor quality.
A German study2 “found insufficient evidence to determine the efficacy or safety of hormonal treatment approaches for transgender women in transition”, adding that “[t]his lack of studies shows a gap between current clinical practice and clinical research.”
A British review3 conducted by the National Institute for Health and Care Excellence (NICE) graded certainty of evidence for puberty blocker use as “very low” in every category, including impact on gender dysphoria, mental health, body image, global functioning, psychosocial functioning, cognitive functioning, bone density and adverse effects.
A chapter4 in an edited volume details the low evidence base for treatment pathways employed at the UK’s Gender Identity Development Service, demonstrating how negative evidence was “ignored or suppressed”.
Finally, a systematic review5 commissioned by the World Professional Association for Transgender Health (WPATH) to “systematically review the effect of gender-affirming hormone therapy on psychological outcomes among transgender people” noted that, in some areas, there was low quality or insufficient evidence.
- D’Angelo, R. (2018). Psychiatry’s ethical involvement in gender-affirming care. Australasian Psychiatry 26 (5): 460-463. [Link] ↩︎
- Haupt, C., Henke, M., Kutschmar, A., Hauser, B., Baldinger, S., Saenz, S.R. & Schreiber, G. (2020). Antiandrogen or estradiol treatment or both during hormone therapy in transitioning transgender women. Cochrane Database of Systematic Reviews 11. [Link] ↩︎
- National Institute for Health and Care Excellence (2021). Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria. National Institute for Health and Care Excellence (NICE); NHS England; NHS Improvement. [Link] ↩︎
- Biggs, M. (2019). The Tavistock’s Experiment with Puberty Blockers. In: Moore, M. & Brunskell-Evans, H. (eds.). Inventing Transgender Children and Young People. Cambridge Scholars Publishing. [Link] ↩︎
- Baker, K.E., Wilson, L.M., Sharma, R., Dukhanin, V., McArthur, K. & Robinson, K.A. (2021) Hormone Therapy, Mental Health, and Quality of Life Among Transgender People: A Systematic Review. Journal of the Endocrine Society 5 (4). [Link] ↩︎
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Puberty blockers are more than a ‘pause button’: roughly 98% of children who take them go on to take cross-sex hormones
A 2021 study from the UK1 found that only 1 out of 44 children placed on puberty blockers did not continue to take cross-sex hormones.
Similarly, a Dutch study2 reported that only 1.9% of adolescents who started puberty suppression treatment abandoned this course and did not take cross-sex hormones.
In fact, in a different Dutch study3, “[n]o adolescent withdrew from puberty suppression, and all started cross‐sex hormone treatment, the first step of actual gender reassignment.”
Puberty blockers are drugs which change young bodies in ways we have yet to understand, and may be permanent. This is an experimental treatment program: puberty blockers have never been licensed to treat children with gender dysphoria, in any country.
- Carmichael, P., Butler, G., Masic, U., Cole, T. J., De Stavola, B. L., Davidson, S., Skageberg, E. M., Khadr, S., & Viner, R. M. (2021). Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK. PLOS ONE 16 (2). [Link] ↩︎
- Wiepjes, C.M., Nota, N.M., de Blok, C.J.M., Klaver, M., de Vries, A.L.C., Wensing-Kruger, S.A., de Jongh, R.T., Bouman, M.B., Steensma, T.D., Cohen-Kettenis, P., Gooren, L.J.G., Kreukels, B.P.C. & den Heijer, M. (2018). The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets. Journal of Sexual Medicine 15 (4). [Link] ↩︎
- de Vries, A.L.C., Steensma, T.D., Doreleijers, T.A. & Cohen-Kettenis, P.T. (2011). Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med 8 (8): 2276-83. [Link] ↩︎