The process of transitioning, and transgender-affirming health care, can be a confusing experience from an outside perspective. Most people are not trans or gender diverse (TGD), and thus will never have any first-hand experience when it comes to transitioning. However, some of the early steps of a medical transition are not exclusive to TGD people.
Puberty blockers are crucial to these first steps, though policy and public perception often are not shaped by the science. A medical transition is not necessary to be considered TGD. Being TGD is unique to each individual; it is impossible to generalize and can include non-physiological aspects of gender expression such as fashion, socialization, and use of a preferred name or pronouns.
My decision to write this article was inspired after reading a piece published in Healthy Debate: “Prescribing compassion: Standing up against transphobic policies in Alberta”. The authors expressed concerns about how transphobic policies may affect TGD youth. While this article was focused on policies specific to Alberta, we need to explore the issue on a broader scale as these types of policies are appearing globally. I share the authors’ call to ensure the policies we enact are based on evidence, and not on personal views about potential slippery slopes.
While reading the article, I noticed that some of the sentiments discussed, in this case by Alberta Premier Danielle Smith, were shared by several commenters below the post. The primary theme was that puberty blockers are not a reversible intervention. In response to these sentiments, which are driven by personal perspectives, the facts of the matter must be clearly articulated. The science is clear. The use of puberty blockers is a reversible method that allows TGD youth (and others) to explore their gender identity, and it is clear that these medical interventions are safe and effective. In fact, they are so safe and effective that medical practitioners prescribe puberty blockers to cisgender youth who are going through precocious puberty.
Precocious puberty is when a child begins exhibiting the characteristics of puberty at an age earlier than typically expected. In these cases, puberty blockers, often leuprolide acetate or triptorelin, may be prescribed to prevent the production of sex hormones triggered by the start of puberty. As a result, the physiological effects of puberty are halted. However, the beginning of the hormone pathway is not blocked by these interventions, and can be restarted by stopping the intervention. Therefore, the effects of puberty blockers are entirely reversible. Youth (and their guardians when applicable) who are concerned that their puberty is beginning too soon can acquire these treatments to pause the pubescent physiological changes until they are ready for them to start. This is the very definition of gender-affirming medical care. Someone is taking action to ensure their physiology aligns with their experience of their gender. It is entirely plausible that an 8-year-old boy growing pubic hair or a 6-year-old girl menstruating would want to experience these changes at the same time as other youth as opposed to having their childhood rushed. I have rarely seen pushback from people opposed to puberty blockers in these cases, or in any policy to prevent cisgender youth from accessing these interventions.
However, there seems to be a push to block access by TGD youth.
When looking at the issue, even from a trans-exclusionary point of view, the facts of each case are nearly identical. In both circumstances, a person/patient is concerned about puberty commencing and is seeking a solution to give them the time to decide how to proceed. In these simplest terms, the primary motivation is the same. Why then, will cisgender-conforming youth have the luxury to undergo these treatments while TGD youth will not?
Additionally, the distress caused by undergoing undesirable pubescent changes is shared among both groups, albeit at possibly different ages. Thus, why should we deny relief to one group and not another, based alone on their gender identity?
The compassionate and evidence-based answer is clear. There should be no additional restrictions for TGD youth seeking this treatment. Across the board, access to this treatment greatly benefits these youth and is only bettered by the fact that it is reversible.
It is not the case that TGD youth are seeking these treatments for reasons not shared by cisgender youth. Both groups are attempting to ensure their physiologies align with their preferred expression of gender, whether that be based on timing or identity, and ought to be treated equally.
Most crucial is the distinction between puberty blockers and hormone replacement therapies (HRT). Puberty blockers are, as mentioned, a reversible medical intervention to allow TGD youth the time they need to understand their gender identity before puberty takes its irreversible toll. HRT, however, is a later stage of TGD health care that involves supplementation of hormones that align with the desired gender expression of the patient. This allows for physiological changes that move away from the gender assigned at birth and toward their current, correct gender identity.
Thus, these two interventions are very different, and both may not be necessary or applied in each situation. It is pertinent to mention, however, that HRT is much more easily accomplished if someone has been on puberty blockers since they would have a blank slate on which the supplemented hormones can operate. Puberty blockers are a safe and reversible option to give TGD youth the time they need to explore their gender identity; views on the use of HRT for this group should not affect the availability or policy surrounding puberty blockers.
Although the evidence around puberty blockers is clear, policy is in motion in Alberta and the United Kingdom to prevent their use by TGD youth. Alberta Premier Smith has stated that puberty blockers would not be prescribed to youth under the age of 16. Furthermore, the Cass Review, the new standard for TGD care in the U.K., has banned puberty blockers for anyone under the age of 18. Both of these prohibitions are targeted at TGD youth, with no mention of restriction to cis youth as a treatment for precocious puberty. These are just two examples of how cis-normative claims with a lack of evidentiary substance can turn into dangerous policies targetting an incredibly vulnerable population like TGD youth.
If we are to comply with these policies, we would not only be harming these youth but would be doing so in the face of contrary evidence. As has been shown many times, puberty blockers are safe and effective and provide a reversible method for TGD youth to explore their identity before puberty can take effect. To prevent only TGD youth from using these interventions would contradict the evidence and would be an unjustifiably discriminatory act.
The Cass Review says allowing access to puberty blockers may prompt TGD youth to move forward with affirmative hormone therapy, which is tantamount to a slippery slope fallacy. This is not the only case in which such a fallacy is invoked, often appearing where other anti-trans policies are posited. Thus, not only do these policies lack evidence, but they also provide fallacious reasoning for their bigotry.
None of the policies preventing puberty blockers can be justified, as they are entirely discriminatory. Unless puberty blockers are banned for all youth – which would be reckless and opposed to my personal views on the matter – it must not be the case that only a minority of youth should be denied the opportunity to access them.
If cisgender-affirming care is on the table, then transgender-affirming care must join it.
Not only is this article providing false and misleading information, it is dangerous. The author writes:
“While reading the article, I noticed that some of the sentiments discussed, in this case by Alberta Premier Danielle Smith, were shared by several commenters below the post. The primary theme was that puberty blockers are not a reversible intervention. In response to these sentiments, which are driven by personal perspectives, the facts of the matter must be clearly articulated. The science is clear. The use of puberty blockers is a reversible method that allows TGD youth (and others) to explore their gender identity, and it is clear that these medical interventions are safe and effective. In fact, they are so safe and effective that medical practitioners prescribe puberty blockers to cisgender youth who are going through precocious puberty.”
No, the science is NOT clear. In fact the science has shown to be very weak and of low to very low quality.
The use of puberty blockers is NOT reversible. In fact, the reversibility claim is from clinical trials done in young patients with precocious puberty, an indication the PBs (GnRH analogs) have been trialed in and registered for administration. The PBs are ceased at about age 11 so the child can commence a natural puberty. This is very different to blocking puberty in adolescence or disrupting it if started as a teen.
No it does not allow adolescents to “explore their identity”. 98% of kids that go on PBs will go on to cross sex hormones. PBs are a gateway drug to further medicalisation and surgery.
The PB side effect profile, which includes the risk of serious psychiatric events, mood changes, bone density degradation, sterility, inability to orgasm, vaginal/uterine atrophy, body aches and pains, is far from safe especially since they are being prescribed to healthy bodies. Not to mention the yet to be discovered side effects on cognitive and psychosocial function because the studies have not been done.
The only thing PBs are effective at in this patient population are stopping puberty and causing sterility. They are not effective at curing gender dysphoria since adolescents continue to be gender dysphoric whilst being administered PBs. They are not “life saving” and effective at improving mental health and reducing suicide since suicide rates increase post transition and suicidal ideation/attempt and completion have been reported for minors taking PBs.
The last sentence – yes they are deemed “safe” for minors with precocious puberty because they have been tested in robust, randomised, controlled clinical trials for this indication and the benefits of blocking early onset puberty in the age group of 1 – 11 yo outweighs the risks of taking the drug. Having said that the treatment itself is risky with the package insert updated for suicidal ideation/attempt.
These same robust clinical trials have not been conducted in adolescents with gender dysphoria.
Until someone is able to publish a systematic review on fertility outcomes in males after puberty blocker treatment for GD (these treatments go on for many more years than for precocious puberty), this is absolutely an unsettled clinical debate and misinformation has no.place in this discussion. Additionally, the systematic reviews that WPATH commissioned, John’s Hopkins carried out, and then WPATH refused to publish are evidence that this domain of medicine is tainted and the so-called “settled science” about the safety of these interventions lacks objectivity. Call it magical thinking, but don’t call it science.
Not only is the claim false (as Peter Sim says) that puberty blockers are known to be reversible when given for gender dysphoria, the citation is incorrect.
The link in “The use of puberty blockers is a reversible method that allows TGD youth (and others) to explore their gender identity, . . .” points to an article that reviews the benefits and harms of puberty blockers but adduces no evidence that they are reversible. It merely makes the assertion in the Introduction of its Abstract.
The citation of this paper as support for the reversibility of puberty blockers is misleading.
Conflating the use of puberty blockers in precocious puberty and gender dysphoria is misleading. Even in precocious puberty, puberty blockers have significant risks that must be carefully considered by the prescribing physician. Effects on neurodevelopment are still vastly unknown, but existing data are concerning (Hayes, 2017, Front. Psychol.; Baxendale, 2024, Acta Pædiatrica). For adult patients treated with Lupron for endometriosis, the treatment lasts only six months, twelve at most.
Also, puberty blockers carry a risk of “locking in” gender dysphoria and preventing its natural resolution, sending the patient on a pathway of lifelong medicalization.
The article repeats false claims about puberty blockers which have been refuted many times. There are no scientific studies which show that puberty blockers for gender dysphoria are reversible. The research on precocious puberty is not applicable to gender dysphoria because the drugs are being used in a different way for a different condition. In the treatment of precocious puberty the drugs are stopped when the child reaches the age that is the normal window for puberty. It has been found that puberty will the proceed as normal. However, with gender-questioning children the drugs are started at the first signs of puberty. Puberty is a developmental window which cannot be repeated and blocking it will have unpredictable effects. No studies have been able to confirm that puberty blockers are reversible because nearly all of the children started on puberty blockers either proceed to cross sex hormones or are lost to follow up. There is evidence that suppressing puberty can lead to reduced bone density and loss of fertility and may have harmful effects on cognitive development.
“The use of puberty blockers is a reversible method that allows TGD youth (and others) to explore their gender identity..,”. I do not think so, that treatment will change the life of the boy or girl forever.
I am a physician and I firmly believe in “Primun non nocere”: First do no harm.
This is misinformation. Let’s first note that the author is NOT a health care professional and is an activist. That’s not a slur, but it frames the qualifications for opining about medical conditions and drugs.
Puberty blockers are approved by Health Canada for precocious puberty because they are used mostly on girls who start puberty very young and are taken off them soon after, at which point normal puberty begins.
Puberty blockers are NOT approved for gender transition, so this is an “off-label” use.
The author notes that puberty blockers for precocious puberty are usually used for children experiencing puberty at ages somewhat younger than normal, and so blockers stop puberty, which restarts at a more normal age,
As the author also notes, puberty blockers for gender dysphoria is more often used on older children who start puberty at a normal age. The intent is to stop puberty so that it never happens. So in addition to the age issue, the purpose is fundamentally different.
There are no good quality studies. They are NOT reversible when used on teens, esp boys. A teen boy on puberty blockers does not develop a normal penis or testes, and does not develop bone density and heart and lung size in the same way as a boy that doesn’t go on puberty blockers.
As a result, teens who use puberty blockers for gender dysphoria do not have sexual function, they have much higher risk of developing osteoporosis in their 20s, higher risk of heart and kidney damage, and there is some evidence that their brains do not fully develop. We know that puberty is an extremely important phase of a person’s life with incredible impacts on our bodies. The use of puberty blockers for gender dysphoria seeks to stop that development.
The Cass review found there is no quality scientific evidence on puberty blockers for gender dysphoria. and that using puberty blockers in this manner is experimental! Yes, we are conducting experiments on kids without the normal safety or ethical controls.
The author says there’s a slippery slope fallacy that teens on puberty blockers will go on hormone therapy. Not at all. Over 90% of kids who go on puberty blockers end up on hormone therapy .. it’s not a slippery slope, it’s a conveyor belt. At that point there is no chance of a typical development pattern for a child, and there is no chance of going back to start again (see the Cass review).
The best evidence at the moment is the Cass Review. It’s independent, not ideological. Read it here:
https://cass.independent-review.uk/home/publications/final-report/
I think you will conclude that the author of this article is simply wrong.
It is total misinformation. Once the negative feedback loop of the HPA axis occurs (gonadotropin analogues – off label) – causing cryptorchidism, the gonads are completely destroyed in boys. These do not recover (exposed prepubertally) to the gonadotropin agonist. Eunuchs are created through infusion overtreatment.