On Monday, the New York Times published an article billed as an in-depth look at puberty blockers as a treatment for gender dysphoria in youth. It wasn’t a guide to the science of the medication, or even just a look at the disagreements in clinical protocol among specific doctors who treat teens. Instead, the piece grappled with whether young trans people should be treated with puberty blockers at all.
It’s a common error for certain journalists to make—viewing an essential piece of transgender health care as a newfangled, untested invention that may pose grave harm. It’s a bias I hope the paper of record seriously considers in its future coverage. In the meantime, as a trans journalist, I wanted to offer a more straightforward look at what puberty blockers are, and how they can help some patients. It’s true they have downsides and that they aren’t right for every young person with gender dysphoria—but this is true of every medication, no matter the patient population. The mainstream medical consensus is that blockers are a useful tool in treating gender dysphoria, and more data is coming in all the time to support their efficacy in the patients for whom they’re indicated. They are currently used only by a small percentage of trans-identifying youth.
Puberty blockers are drugs that disrupt the release of sex hormones. The primary drug used is called Lupron, and it has been prescribed for over 30 years, in a variety of medical contexts, to treat both children and adults. In addition to being used for prostate cancer, for endometriosis, and to address the distressing psychological effects of early puberty, it’s used (rarely!) to halt puberty for adolescents experiencing severe gender dysphoria.
A good starting place for thinking about puberty blockers—one the Times mentions only in passing—is to consider their use in children with precocious puberty. This is a deeply distressing condition, for both children and parents, in which a young child begins to develop the secondary sex characteristics more typically found in adolescents. This results in looking different from their peers, which can cause social issues. There can also be a lot of stress associated with early menstruation or other pubertal changes.
However, there are no physical health risks associated with precocious puberty. Drugs that halt early sexual maturity provide children with the opportunity to be more like their peers in appearance and maturity. The side effects of Lupron are generally considered tolerable enough that these psychological benefits are well worth the risks of treatment—though this can of course vary on an individual basis.
Gender-dysphoric youth, coincidentally, can also experience psychological and social benefits from these same drugs. Pausing puberty can allow youth to be accepted socially and prevent the intense psychological distress that so often accompanies puberty in gender-dysphoric teens. These are the great benefit of the drugs, as well as the fact that they’re entirely reversible, meaning that if treatment is stopped, puberty will recommence normally. There are side effects, but the mainstream medical consensus has been that these drugs are well known in other applications, and that for trans youth, as for other populations, the benefits can outweigh the risks.
The Times, however, does not seem to trust that medical consensus view. Instead, it focuses on one potential issue: reduced bone density. Bone density increases greatly in adolescence, under the influence of sex hormones. By halting puberty, Lupron also halts the expected increase in bone density. A 2017 investigation by Kaiser Health News looked at women who had used Lupron as teens to delay precocious puberty and who later in life reported side effects like osteoporosis and cracking teeth. It is difficult to suss out whether these side effects were definitely caused by Lupron, the Kaiser Health News investigation concluded.
For youth with preexisting bone density issues, all this may be a reason not to arrest puberty, for whatever reason, using blockers. For other youth, the best practice is to discuss the potential risks and benefits. If the drugs are the right choice, a doctor should conduct regular bone density scans if the youth and family decide to move ahead with treatment. The Times piece notes two instances in which young people on blockers did not receive appropriate bone scans during treatment; one of those patients “developed osteoporosis and sustained a compression fracture in his spine.” But this oversight seems like a point in favor of improving access to health care for trans youth, not limiting it. It’s also important to note that laws introduced in states like Tennessee and Florida to outlaw blockers for gender-dysphoric youth have all included language allowing them to be used to prevent early puberty.
Medications almost always have side effects, and a calculation between the harms (or potential harms) and the benefits of treatment is a routine one in every area of medicine. If puberty blockers still sound scary, it’s useful to think about how other medications are used for young people. Birth control is a medication with extensive, sometimes serious side effects, including an increased risk of heart attack and stroke. Many doctors, parents, and adolescents agree that the risk of teenage pregnancy greatly outweighs the risks of these rare complications, but there are also many common, though more minor, side effects. Another useful comparison point is psychiatric medications, such as SSRIs, mood stabilizers, and antipsychotics. These medications often have quite severe side effects, and their use in children has been criticized, though never at the level of the current moral panic over puberty blockers.
There are genuine quibbles to be had with how, say, SSRIs are prescribed—namely, doctors could do a better job of discussing the downsides and helping patients access other treatment options like talk therapy. There should be more research into side effects like decreased sexual functioning. But the locus of those discussions should be between the provider and the patients; it’s not a question of whether they are prescribed but of giving patients the right information and space to ask questions before either beginning a prescription or deciding it’s not right for them. The same holds true of puberty blockers. Ironically, most alternative treatments for the depression and anxiety and suicidal ideation caused by untreated gender dysphoria are likely to involve psychiatric medications—which can themselves, particularly antipsychotics, come with severe side effects.
None of this context was mentioned by the Times. Something that was mentioned, but downplayed, is how few kids are actually being treated with puberty blockers in the U.S. There are over 25 million youth between the ages of 12 and 17 in this country. The best estimate of how many children are on puberty blockers, according to a recent Reuters investigation, is roughly 5,000. The percentage of U.S. children from 13 to 17 on puberty blockers for gender dysphoria, therefore, calculates to .02 percent. The Times estimates that 300,000 U.S. youth identify as trans. Five thousand is less than 2 percent of those trans-identifying youth. A much, much higher percentage of youth have been on a diet.
If that picture were to change with new data, best practices and recommendations of the medical establishment would change in order to reflect that. At this time, fearmongering aside, there is no reason to believe that puberty blockers are not a safe and effective treatment option for youth experiencing severe gender dysphoria. The only reason to fear kids’ using them stems from a fear of trans people themselves.
