Are puberty blockers helpful or harmful to trans youth?
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Q: Are puberty blockers helpful or harmful to trans youth?
A: Current evidence suggests that puberty blockers, which hit the pause button on puberty and are reversible, significantly improve the mental health of trans youth while reducing the risk of needing future surgeries.
A recent study showed that trans teens who were treated with puberty blockers had significantly less anxiety, depression, and stress compared to trans kids who did not receive such treatment. This is one of the largest studies yet to show significant benefit associated with puberty blockers.
Puberty blockers are medications that can (reversibly) pause puberty for a period of time. With them, trans youth can avoid (or delay) irreversible physical changes that are out of line with their gender identity. For example, for a trans girl, developing a deepened voice, large Adam’s apple, and facial hair can be very distressing. It is also permanent - no amount of future hormone therapy will change those characteristics. Puberty blockers can prevent that. For a trans boy, breast development, once it occurs, is often very distressing and is also permanent - the only future option is surgery. This distress, called gender dysphoria, is associated with significantly increased risks of depression, anxiety, and suicidality, and poor social functioning in trans youth.
Using puberty blockers gives trans youth a span of time (up to a few years) before any irreversible changes happen to their bodies, either from the puberty their body was planning to do, or from taking hormone therapy right away. This window of time can be very helpful in working with their counselor, medical team, and families to figure out what future interventions, if any, are right for them.
For those who go on to start hormone therapy, prior use of puberty blockers gives the advantage of not having as many body characteristics that are out of line with their gender. This can alleviate a lot of personal distress (e.g. gender dysphoria) and make it much easier to navigate the world.
In the recent study, researchers looked at the mental health of 438 trans youth aged 13-17 who were coming in for a hormone readiness assessment visit. They found that patients who’d received treatment with puberty blockers had significantly fewer symptoms than those who hadn’t. This study used the Youth Self Report, an extensively validated and widely used survey in pediatrics, on which a score of 50 is the population average and above 70 indicates clinical severity. Youth who’d had puberty blockers scored lower (better), by about 5 points in each category, for symptoms of anxiety, depression, stress, and overall problems.
There are some limitations to this study. The groups were not randomized, so there could be other differences between the two groups that resulted in the different outcomes. For example, it’s possible that youth who received puberty blockers had an even higher level of family support than those who didn’t. Because family support has been shown to be a significant factor in the mental health of trans youth, that could explain some of the lower symptoms scores. We will likely never have a randomized study, however, because that would require denying access to puberty blockers to one of the groups. Given evidence showing they are helpful, that would be unethical. Another limitation of this study is that all of these subjects were attending a comprehensive specialty gender clinic in a major city. Therefore, they all had very high levels of family support and tended to be majority white and affluent. Therefore, this study does not reflect the general population of trans youth.
A strength of this study is that its findings of improved mental health are in line with several other studies (See here, and here, and here.) that show decreased self-harm, depression, and/or suicidality in youth who receive puberty blockers. This is important, as trans youth have a 2-3 times higher risk of suicidality than non-trans youth. Use of puberty blockers, therefore, does seem to help prevent suffering and increase the likelihood of a happy and healthy adolescence and adulthood. It may even be life-saving.
Puberty blockers have been in use for several decades for a variety of health conditions and seem to be quite safe. There is a risk of loss of bone density (that is reversible when the medication is stopped), so many patients take Vitamin D and calcium, get weight-bearing exercise, and have routine bone scans to make sure things are ok. Research shows no impact on final adult height, fracture risk, or future fertility. Even so, the decision to start puberty blockers is usually made only after careful and extensive evaluation of the patient and discussion with their family.
In sum, puberty blockers appear to be helpful for trans youth. They are associated with significantly improved well-being and decreased need for future surgeries. There is no evidence of significant harm. Therefore, all major medical organizations in the U.S. support their use when they are deemed appropriate by the clinician, patient, and family.
Resources:
Info on puberty blockers from Mayo Clinic
Medical organizations that support gender affirming care of trans youth
American Academy of Pediatrics policy supporting care for transgender youth
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I find it concerning that this blog claims expertise in "evidence-based medicine" but when addressing questions of mental health effectiveness, harm, and "reversability" of puberty blockers cites a single observational study when there are existing systematic evidence revews that address the same questions, but come to different answers.
For example, the Ludviggsson et al systematic review finds that bone health measures did not recover to pre-treatment levels after puberty suppression in all subjects, and that mental health benefits were inconclusive. https://onlinelibrary.wiley.com/doi/10.1111/apa.16791
These results undercut the argument that denying access to puberty blockers would harmful because we don't actually know if the blockers are beneficial. And even the linked study appears to have "denied access" to 398 study participants (unclear without the full text).
How do you reconcile this with claims to be "evidence based"?