New Paper Says Puberty Blockers Aren’t the Answer to Gender Confusion

By Ryan T. Anderson,  William E. Simon Senior Research Fellow in American Principles and Public Policy at The Heritage Foundation

Increasingly, gender therapists and physicians argue that children as young as nine should be given puberty-blocking drugs if they experience gender dysphoria.

But a new article by three medical experts reveals that there is little scientific evidence to support such a radical procedure.

The article, “Growing Pains: Problems with Puberty Suppression in Treating Gender Dysphoria,” published Tuesday in The New Atlantis, discusses over 50 peer-reviewed studies on gender dysphoria in children.

It is co-authored by Dr. Paul W. Hruz, a professor at Washington University School of Medicine, Dr. Lawrence S. Mayer, a scholar in residence at the Johns Hopkins University School of Medicine and a professor at Arizona State University, and Dr. Paul R. McHugh, University Distinguished Service Professor of Psychiatry at the Johns Hopkins University School of Medicine.

Last year, Mayer and McHugh published an extensive report on sexuality and gender in general. Now, working with Hruz, an expert on pediatrics, they focus on children.

As I explain in my forthcoming book, “When Harry Became Sally: Responding to the Transgender Moment,” the best biology, psychology, and philosophy all support an understanding of sex as a bodily reality, and of gender as a social manifestation of bodily sex.

Biology isn’t bigotry, and we need a sober and honest assessment of the human costs of getting human nature wrong. This is especially true with children.

And yet, pediatric gender clinics—and therapeutic interventions on children—are on the rise. In the past ten years, dozens of pediatric gender clinics have sprung up throughout the United States.

In 2007, Boston Children’s Hospital “became the first major program in the United States to focus on transgender children and adolescents,” as their own website brags.

Seven years later, 33 gender clinics had opened their doors to our nation’s children, telling parents that puberty blockers and cross-sex hormones may be the only way to prevent teen suicides.

Never mind that according to the best studies—the ones that even transgender activists themselves cite—80 to 95 percent of children with gender dysphoria will come to identify with and embrace their bodily sex.

Never mind that 41 percent of people who identify as transgender will attempt suicide at some point in their lives, compared to 4.6 percent of the general population.

Never mind that people who have had transition surgery are 19 times more likely than average to die by suicide.

These statistics should stop us in our tracks. Clearly, we must work to find ways to effectively prevent these suicides and address the underlying causes. We certainly shouldn’t be encouraging children to “transition.”

The sad reality is that while the number of pediatric gender clinics is growing, very little is known about gender identity in children—and many therapies amount to little more than experimentation on minors.

Professional standards of care are being promulgated that state children should receive puberty-blocking drugs at as young as age nine, and cross-sex hormones at age 16—but there have been no controlled clinical trials on puberty blocking for gender dysphoria, and the FDA has not approved these drugs for treatment of gender dysphoria.

Meanwhile, despite claims by advocates, there is no evidence that puberty blocking is “reversible,” nor that it is harmless. Most concerning of all is that these treatments run the risk that children may persist in their gender dysphoria.

Blocking Puberty Could Cause Children to Persist in Gender Dysphoria

In their new article, Hruz, Mayer, and McHugh explain that transgender-affirming treatments of children “may drive some children to persist in identifying as transgender when they might otherwise have, as they grow older, found their gender to be aligned with their sex.”

As the doctors note, “Gender identity for children is elastic (that is, it can change over time) and plastic (that is, it can be shaped by forces like parental approval and social conditions).”

As a result, if “the increasing use of gender-affirming care does cause children to persist with their identification as the opposite sex, then many children who would otherwise not need ongoing medical treatment would be exposed to hormonal and surgical interventions.”

Whereas 80 to 95 percent of children with gender dysphoria will come to identify with and embrace their biological sex, none of the children placed on puberty blockers in the Dutch clinic that pioneered this treatment came to identify with their biological sex. All of them persisted in their transgender identity.

Indeed, as Hruz, Mayer, and McHugh explain, for children placed on puberty blockers, “[r]ather than resuming biologically normal puberty, these adolescents generally go from suppressed puberty to medically conditioned cross-sex puberty, when they are administered cross-sex hormones at approximately age 16.”

The doctors worry that transgender-affirming treatment, puberty blockers, and cross-sex hormones “may have solidified the feelings of cross-gender identification in these patients, leading them to commit more strongly to sex reassignment than they might have if they had received a different diagnosis or a different course of treatment.”

The Dutch doctors who pioneered puberty blocking as a treatment for gender dysphoria argue that it would give a child “more time to explore their gender identity, without the distress of the developing secondary sex characteristics.”

This is an odd argument. As Drs. Hruz, Mayer, and McHugh explain, “It presumes that natural sex characteristics interfere with the ‘exploration’ of gender identity, when one would expect that the development of natural sex characteristics might contribute to the natural consolidation of one’s gender identity.”

The rush of one’s natural sex hormone and the bodily development that takes place during puberty may be the very thing that helps a developing boy or girl come to appreciate and identify with their bodily sex. And yet puberty blockers would prevent this from taking place.

Hruz, Mayer, and McHugh highlight the possibility that “the interference with normal pubertal development will influence the gender identity of the child by reducing the prospects for developing a gender identity corresponding to his or her biological sex.”

>>> For more on this, see Ryan T. Anderson’s forthcoming book, “When Harry Became Sally: Responding to the Transgender Moment.”

So the treatments proposed by transgender activists—social transition followed by puberty suppression, cross-sex hormones, and possibly surgery—make it more likely that children will engage in self-reinforcing activity that may make desistence less likely. Anything that would encourage a child to persist in identifying as transgender should give us pause.

As Dr. Hruz explained to a federal court:

Desistance (i.e. reversion to gender identity concordant with sex) provides the greatest lifelong benefit and is the outcome in the majority of patients and should be maintained as a desired goal. Any intervention that interferes with the likelihood of resolution is unwarranted and potentially harmful.

Puberty Blocking Is Experimental

Not only does a trans-affirming therapeutic approach run the risk of prolonging transgender identities in children who otherwise would have grown out of them, so too it is entirely experimental. It is not supported by any rigorous science. And there is no way of knowing if it is even safe, let alone effective.

Hruz, Mayer, and McHugh respond to the promotion of these standards of care by various activist—and, sadly, professional—organizations:

Reading these various guidelines gives the impression that there is a well-established scientific consensus about the safety and efficacy of the use of puberty-blocking agents for children with gender dysphoria, and that parents of such children should think of it as a prudent and scientifically proven treatment option. But whether blocking puberty is the best way to treat gender dysphoria in children remains far from settled and it should be considered not a prudent option with demonstrated effectiveness but a drastic and experimental measure.

Experimental medical treatments for children must be subject to especially intense scrutiny, since children cannot provide legal consent to medical treatment of any kind (parents or guardians must consent for their child to receive treatment), to say nothing of consenting to become research subjects for testing an unproven therapy. In the case of gender dysphoria, however, the safety and efficacy of puberty-suppressing hormones is not well founded on evidence … Whether puberty suppression is safe and effective when used for gender dysphoria remains unclear and unsupported by rigorous scientific evidence.

The sad reality is that prolonged puberty suppression as a treatment for gender dysphoria has “been accepted so rapidly by much of the medical community, apparently without scientific scrutiny, that there is reason to be concerned about the welfare of children who are receiving it, as well as reason to question the veracity of some of the claims made to support its use—such as the assertion that it is physiologically and psychologically ‘reversible.’”

Puberty Blocking Isn’t ‘Reversible’

Indeed, the way that activists talk makes it seem like normal human development is an irreversible problem, but interfering with development is a cautionary and fully reversible step.

But actually the opposite is true, as Hruz, Mayer, and McHugh explain:

This turns the normal language of reversibility on its head, speaking of the natural process of biological development as an irreversible series of problems that medicine should seek to prevent, while presenting the intervention—puberty suppression—as benign and reversible.

But doctors have no way of knowing whether these treatments truly are reversible, because very few people have ever sought to have them reversed: “There are virtually no published reports, even case studies, of adolescents withdrawing from puberty-suppressing drugs, and then resuming the normal pubertal development typical for their sex.

Or, at least, perhaps not in a normal way. After all, as Hruz, Mayer, and McHugh explain, “In developmental biology, it makes little sense to describe anything as ‘reversible.’”

Going through a developmental process at age 20 that should take place at age 10 is not the same thing. So talk about these treatments being reversible is inherently misleading.

And yet all of the major activist groups—and many professional groups—perpetuate this claim.

But as Hruz, Mayer, and McHugh illustrate, “If a child does not develop certain characteristics at age 12 because of a medical intervention, then his or her developing those characteristics at age 18 is not a ‘reversal,’ since the sequence of development has already been disrupted.”

In essence, doctors are engaging in a giant experiment on minors by blocking their maturation, and they are doing this without even coming close to the ethical standards demanded in other areas of medicine.

So while the “claim that the initial treatments are reversible may make them seem less drastic,” this claim “is not well supported by evidence.”

As Hruz, Mayer, and McHugh explain, “It remains unknown whether or not ordinary sex-typical puberty will resume following the suppression of puberty in patients with gender dysphoria.”

Puberty Blocking May Have Long-Term Health Consequences

There are also long-term health risks associated with the use of puberty blockers for gender dysphoria, though no one really knows all of the potential consequences, since this use has not been rigorously studied.

Nevertheless, as the doctors explain, “some of the known effects of puberty suppression on physiologically normal children are what you would expect from alterations made to that critical stage of human development.”

In both boys and girls, it negatively impacts their growth rates in terms of height. Children placed on puberty blockers also have an increased risk of low bone-mineral density. Hruz notes that “[o]ther potential adverse effects include disfiguring acne, high blood pressure, weight gain, abnormal glucose tolerance, breast cancer, liver disease, thrombosis, and cardiovascular disease.”

And, of course, all of the children who persist in their transgender identity and take puberty blockers and cross-sex hormones will be infertile.

Here’s how McHugh, Hruz, and Mayer, citing sources for each claim, put it in their Supreme Court brief:

Puberty suppression hormones prevent the development of secondary sex characteristics, arrest bone growth, decrease bone accretion, prevent full organization and maturation of the brain, and inhibit fertility. Cross-gender hormones increase a child’s risk for coronary disease and sterility. Oral estrogen, which is administered to gender dysphoric boys, may cause thrombosis, cardiovascular disease, weight gain, hypertriglyceridemia, elevated blood pressure, decreased glucose tolerance, gallbladder disease, prolactinoma, and breast cancer. Similarly, testosterone administered to gender dysphoric girls may negatively affect their cholesterol; increase their homocysteine levels (a risk factor for heart disease); cause hepatotoxicity and polycythemia (an excess of red blood cells); increase their risk of sleep apnea; cause insulin resistance; and have unknown effects on breast, endometrial and ovarian tissues. Finally, girls may legally obtain a mastectomy at sixteen, which carries with it its own unique set of future problems, especially because it is irreversible.

Not surprisingly, given how little we know, the use of drugs for puberty suppression for children with gender dysphoria is not FDA-approved. But the off-label prescription of such drugs is legal.

The bottom line, for Hruz, Mayer, and McHugh is that “we frequently hear from neuroscientists that the adolescent brain is too immature to make reliably rational decisions, but we are supposed to expect emotionally troubled adolescents to make decisions about their gender identities and about serious medical treatments at the age of 12 or younger.”

This new article in “The New Atlantis” should make all of us pause before embracing radical medical treatments for children.

As I explain in “When Harry Became Sally,” the most helpful therapies focus not on achieving the impossible—changing bodies to conform to thoughts and feelings—but on helping people accept and even embrace the truth about their bodies and reality.

Rejecting human nature has real human costs.

*Originally published in The Daily Signal, click here.

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