Puberty Blockers Can Help Transgender Youth. Is There a Cost? - The New York Times

• There was a medical conscious about the medical good of lobotomies in the middle of the 20th century, there was a medical consensus on the seriousness of phenology and of eugenics for many many decades and those were all proven to be terribly wrong and very harmful to whom had to suffer the experiments. So how are you so confident especially in the face of so much medical literature that contradicts your view that it’s worthwhile to experiment on these kids today? (Michael Knowles)

Countries Banning or Restricting

Several countries have either banned or imposed restrictions on the use of puberty blockers for transgender youth, often citing concerns over the lack of long-term research on their effects and the need for more evidence-based approaches. Here’s a summary based on the information available:

• United Kingdom:
  • Banned: The UK has indefinitely banned new prescriptions of puberty blockers for transgender minors outside of clinical research settings. This ban affects England, Scotland, Wales, and Northern Ireland, with exceptions for those already on the medication or for treating precocious puberty.
• Sweden:
  • Restricted: Sweden has restricted the use of puberty blockers to exceptional cases under clinical guidelines, emphasizing the need for more research. The Karolinska Hospital has ended the routine prescription of puberty blockers for minors.
• Finland:
  • Restricted: Finland recommends psychotherapy as the first line of treatment, with puberty blockers used only under strict conditions and after comprehensive mental health assessments. The treatment is seen as experimental.
• Norway:
  • Restricted: Norway has limited the use of puberty blockers to clinical trials, essentially treating their use as experimental.
• Denmark:
  • Restricted: Denmark has shifted towards providing more therapeutic support rather than medical interventions like puberty blockers, which are now prescribed in only a small percentage of cases.
• Netherlands:
  • Reviewing: While not yet having imposed a ban, the Netherlands, where the Dutch protocol for transgender care originated, is re-evaluating the use of puberty blockers, with some voices calling for restrictions similar to those in other European countries.
• France:
  • Cautious Approach: France has not banned but has recommended “the greatest reserve” in prescribing puberty blockers, highlighting potential long-term effects and encouraging more research.
• Belgium:
  • Reviewing: There’s a growing demand in Belgium to reintroduce the restrictions of the original Dutch protocol, indicating a cautious shift in policy.
• Italy:
  • Restricted: Italy’s National Bioethics Committee recommends that puberty blockers should only be provided after mental health interventions have failed and within proper research trials.
• Spain:
  • Specialist Care: Puberty blockers are available through specialist care, but there’s no outright ban or restriction at the national level, though regional policies might vary.
• New Zealand:
  • Cautious: While not banned, there’s a recommendation for a more precautionary approach, with one doctor noting it wouldn’t change his practice.

These policies reflect a broader trend in Europe towards caution, emphasizing the need for more robust research before widespread prescription can continue. It’s important to note that these restrictions often apply specifically to the treatment of gender dysphoria in minors and not necessarily to other medical conditions like precocious puberty where blockers might still be used.

Consequences of Puberty Blockers

Puberty blockers, or gonadotropin-releasing hormone agonists (GnRHas), are used to delay the onset of puberty in individuals experiencing gender dysphoria or precocious puberty. Here are the known and potential consequences based on available research:

Physical Consequences:

• Bone Health:
  • Decreased Bone Density: Puberty blockers can lead to reduced bone density because the accrual of bone mass during puberty is crucial. This might increase the risk of osteoporosis or fractures later in life. Some studies suggest that this effect might be partially reversible once hormone therapy begins, but long-term outcomes are still under investigation.
• Growth:
  • Height: While blockers can prevent early closure of growth plates, which is beneficial in cases of precocious puberty, the long-term effects on final height in transgender youth are not fully understood. There’s a potential for altered growth trajectory if used extensively.
• Fertility:
  • Potential Impact: Puberty blockers might affect fertility if used for prolonged periods, especially if followed by cross-sex hormones without a period of pubertal progression. However, the effects on fertility are not fully known, and some research suggests that fertility might be preserved if blockers are used for a limited time.
• Sexual Development:
  • Delayed Sexual Maturation: Puberty blockers halt the development of secondary sexual characteristics. If an individual decides not to proceed with hormone therapy, resuming puberty after discontinuation of blockers might not fully catch up all aspects of sexual maturity.

Psychological and Social Consequences:

• Mental Health:
  • Positive Impact: For many transgender youth, blockers can significantly reduce gender dysphoria, leading to improved mental health outcomes, including lower rates of depression and anxiety, and potentially reducing suicidal ideation.
  • Uncertainty and Stress: However, the decision to use blockers can also come with its psychological stressors, including the pressure of decision-making, potential societal stigma, or concerns about future health implications.
• Identity Development:
  • Time for Exploration: Blockers provide time for gender identity exploration without the distress of unwanted physical changes, which can be seen as a psychological benefit.
  • Potential for Locking in Identity: Some critics argue that blockers might “lock in” a gender identity prematurely, though this is contested, with research suggesting that many who use blockers continue to identify as transgender into adulthood.

Long-term Health Concerns:

• Brain Development: There’s limited research on the impact of puberty blockers on brain development. Concerns exist about potential effects on cognitive functions or emotional development due to the role of hormones in brain maturation.
• Cardiovascular System: While not extensively studied in transgender youth, the long-term effects on cardiovascular health are another area of concern, particularly regarding how hormone treatments post-blockers might influence heart health.

Social and Ethical Considerations:

• Consent and Autonomy: There’s debate over the capacity of minors to provide informed consent for treatments with long-term implications. This includes discussions on whether children can fully understand the consequences of delaying puberty.
• Legal and Policy Issues: The use of puberty blockers has become politically contentious, with some regions imposing restrictions or bans, which can affect access to care and influence the psychological well-being of transgender youth.

Conclusion:

The use of puberty blockers is a complex issue balancing potential benefits against risks that are not yet fully understood due to the lack of long-term studies. The medical community generally supports their use under careful supervision and with thorough counseling to ensure informed decision-making, but ongoing research is crucial to better understand all implications.

Individuals considering puberty blockers should have access to comprehensive care that includes mental health support, regular monitoring (especially for bone health), and discussions about future fertility options.

Studies

NIH

The National Institutes of Health (NIH) does not conduct studies directly but funds research through various grants and supports research through its institutes like the National Institute of Mental Health (NIMH) or the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). However, there are several studies funded or cited by NIH that have investigated the relationship between gender-affirming care and suicidality. Here’s a summary based on the web results provided:

Key Studies:

1. Study on Gender-Affirming Hormone Therapy (GAHT) and Mental Health:

   • Source: The Trevor Project, which receives funding from NIH, conducted a study looking at the association between GAHT and mental health outcomes in transgender and nonbinary youth.
   • Findings:
     • Depression: GAHT was associated with nearly 40% lower odds of recent depression.
     • Suicide: There was also a notable reduction in suicidal thoughts and suicide attempts among those who received GAHT compared to those who did not but wanted it. Specifically, youth under 18 who received GAHT had lower odds of a past-year suicide attempt.
     • Parental Support: Nearly 80% of those receiving GAHT had at least one supportive parent, highlighting the role of family support in accessing care.

2. Study on Gender-Affirming Surgeries:

   • Source: A study supported by NIH research infrastructure, published in JAMA Surgery, examined the mental health outcomes post-gender-affirming surgery.
   • Findings:
     • Mental Health Improvement: Gender-affirming surgeries were associated with a 42% reduction in psychological distress and a 44% reduction in suicidal ideation compared to those who desired but had not undergone surgery.
     • Substance Use: There was also a 35% reduction in tobacco smoking among those who had surgery.

3. Longitudinal Cohort Study:

   • Source: Research from an urban multidisciplinary gender clinic, which might have NIH funding or support, focusing on youths receiving gender-affirming care.
   • Findings:
     • Reduction in Depression and Suicidality: Over 12 months, those who received puberty blockers or gender-affirming hormones had 60% lower odds of depression and 73% lower odds of suicidality compared to those who did not receive such care. However, there was no significant change in anxiety levels.

Critiques and Considerations:

• Methodology Concerns: Some studies have been criticized for their cross-sectional nature, lack of randomized control groups, or for not adequately controlling for confounders like existing mental health conditions or the supportive environments that might facilitate access to care.
• Causality: The association between reduced suicidality and gender-affirming care does not necessarily imply direct causation due to the complexity of mental health outcomes.
• Diverse Outcomes: Not all studies show uniform positive results, and there’s a call for more rigorous, long-term research to confirm these findings across different demographics and settings.

Conclusion:

While the available research, including studies with NIH connections, suggests that gender-affirming care might be associated with reduced suicidality and improved mental health outcomes for transgender individuals, these findings are part of a larger, ongoing research conversation. The current data supports the potential benefits of such care, but there’s a need for more nuanced studies to address the methodological critiques and to understand the full spectrum of outcomes over the long term.