Puberty, Interrupted

a research review on the mental, physical, and lifelong tolls of administering puberty blockers to gender dysphoric children

Everyone goes through puberty. We all experienced it: the awkwardness, the acne, the overnight change in appearance. Looking in the mirror and seeing the difference in your body is uncomfortable. But for children with gender dysphoria, the changes from puberty can feel even more unwelcome. Gender dysphoric children, also known as transgender children, feel an incongruence between their biological sex and gender identity from a young age. During puberty, adolescents develop secondary sex characteristics based on their male or female sex, most of these being irreversible. So, for children with gender dysphoria, a treatment to halt these irreversible changes is being explored: puberty blockers. But there is conflicting information about how puberty blockers affect these children long-term, and the hospitals who administer them warn that there may be side effects that are not yet known. After reviewing the current research, I argue that giving puberty blockers to transgender children is too risky, because “pausing puberty” is not a fully reversible treatment, puberty has physical and psychological benefits that cannot be replicated after puberty blockers are administered, and children are not fully equipped to understand the consequences of this decision.

What is puberty, and what are puberty blockers? When puberty starts, a complex chain reaction is occurring in the body. A hormone called GnRH (gonadotropin-releasing hormone) begins activating in pulses, and these pulses signal to the pituitary gland that it’s time to secrete the hormones that increase the production of estrogen and testosterone, among other sex hormones (Palmert and Dunkell). These increased levels of testosterone and estrogen cause secondary sex characteristics to appear. Testosterone causes changes such as a deeper voice and facial hair for males, while estrogen causes things like breast development and wider hips for females. Puberty blockers – also known as GnRH analogues – work by releasing a constant stream of GnRH. Because the GnRH is no longer activating in pulses, the puberty blockers signal the body to stop producing sex hormones. This prevents the unwanted development of secondary sex characteristics, which is the goal for children with gender dysphoria.

Even though testosterone and estrogen are suppressed with a GnRH analogue, the parathyroid and growth hormones are not. These hormones have several functions during puberty, one of the most important being bone growth. This means that even though the sex hormones are halted, the bones will continue to develop. In two articles, it was shown that children undergoing puberty blockers have lower bone density than their peers of the same age, and don’t go through the same massive spike in growth that other adolescents do (Grant et al., Lee et al.).  This is a huge problem for these children, because the bone mass accrued during puberty determines peak bone mass for life (Saggese et al.). If these children go on to further their gender transition with cross-sex hormone therapy, it is currently unknown whether they develop that bone mass later, even when hormone levels match that of their peers (Lee et al.).

Puberty signals a transition from childhood to adulthood, and the secondary sex characteristics are not the only physical changes. The biological goal of puberty is to develop the sex organs and the reproductive system as well as increase hormone production to eventually encourage sexual desire and reproduction. Puberty blockers administered before proper growth of the sexual and reproductive organs have lifelong consequences. If the child continues onto cross-sex hormones after halting this crucial physical development, inability to orgasm and sterility are both possible irreversible side effects (Economist).

Because the number of gender dysphoric children has been growing over the last decade, family planning conversations should become an important part of the process before proceeding with puberty blockers and cross-sex hormones. One study indicated that for children who were educated about the risk of sterility, “only 13% were referred to fertility preservation clinics.” Another study showed that although gender dysphoric youth have little interest in having kids, half of them questioned whether their feelings might change as they got older (Compton). It is realistic for a child to think they might never want to be a parent, nor be interested in sex. But these children are making a permanent decision to never have a biological child or experience sexual pleasure. This controversial practice has prompted some physicians to recommend gender dysphoric adolescents stop puberty blockers long enough to develop the reproductive organs and freeze eggs or sperm before beginning cross-sex hormones so they preserve the chance to have a biological child if they ever change their minds.

Brain development is another crucial component of the shift from childhood to adolescence, and there is growing evidence to suggest that hormones play a significant role in this transition. During puberty, “the brain is a major target for sex-steroid hormones” (Peper and Dahl). These hormones attach to brain cells, accelerating brain growth and changing the way we learn (Barendse, et al.). Children who start puberty blockers before this development takes place halt brain growth indefinitely unless the sex hormones in their body go back to a comparable level to their peers. Even then, this growth might never occur. According to the NHS (National Health Service) of England, “Little is known about the long-term side effects of hormone or puberty blockers in children with gender dysphoria… it is not known what the psychological effects may be. It's also not known whether hormone blockers affect the development of the teenage brain” (BBC). The NHS administers puberty blockers and recommends them as a “reversible” treatment, despite these risks.

According to proponents of childhood transition, the physical and psychological benefits of going through puberty and the dangers of blocking it are not as important as putting a stop to the distress that comes from believing they were born in the wrong body.

In the book Inventing Transgender Children and Young People, Heather Brunskell-Evans and Michele Moore write about the risks of children transitioning. A common belief argued by supporters of childhood transition is that “if a child says they are in the ‘absolute wrong body’ by early adolescence, they are ‘extremely unlikely’ to change their minds,” (Brunskell-Evans and Moore). This quote from Mayo Clinic, one of the most popular hospitals in America, exemplifies this belief: “while children might go through periods of insisting that they are the opposite gender of their birth sex, if they continue to do so it was likely never a phase” (Mayo). But research has started to show that the majority of transgender children do not go on to become transgender adolescents or adults. Without the influence of puberty blockers, they return to identifying with their birth sex, as the gender dysphoria dissipates during puberty (Giordano). The reason behind this dissipation is often due to the development of sexuality during puberty and the realization that gender dysphoria was an expression of their same-sex attraction. They then go on to identify as gay men or lesbians in adulthood (Shrier).

Many advocates praise puberty blockers because they believe it works as an intervention to “hit a pause button” for gender dysphoric youth, “buying time” for them to figure out if transitioning is the right decision for them. But when puberty blockers are administered, there is little room left for children to doubt. Their brain development is halted, their physical development is halted, and they are no longer on the same level as their peers. This pressures them into transitioning, because if they are on puberty blockers, the next “logical step” is to transition. Very few of them would ever consider stopping puberty blockers, even if they are unsure. According to a study published on WebMD, most children who take puberty blockers will go on to transition with cross-sex hormones. “Therefore, far from being reversible, puberty blockers appear to be a ‘one-way path’ to medical transition” (Ault). In a study spanning several years, only one child out of forty-three who were administered puberty blockers changed their mind and resumed biological puberty (Carmichael, et al., p. 40). If there are children with gender dysphoria out there who don’t transition and grow up to be happy same-sex-attracted individuals, how would a child put on puberty blockers cope when they grow up and begin regretting the irreversible changes from their gender transition, wishing they had never gone through it?

During two personal one-on-one interviews conducted for this research, although both participants ended up on cross-sex hormones as the study by Carmichael, et al. implies, these perspectives from adolescents with gender dysphoria show the complexities of puberty blockers and gender transition. Julius Boulos, a 19-year-old self-identified transsexual man, was administered puberty blockers at age 15 and ended up on estrogen, then on testosterone.

“I had already begun puberty by the time I was 15… but since I had hormonal issues already, I wasn’t functioning as a regular female would. It would often be that my [testosterone] levels were too high, and I had no estrogen, or it would fluctuate and be the opposite… I was told that [puberty blockers] would help me figure out for sure what felt right… when I was 16-18, I was practically forced by my parents to work on my estrogen… today I am around 2 months on [testosterone] and I’ve felt great since.”

A 17-year-old male-to-non-binary person began the puberty blocker known as Lupron at age 15 and experienced severe side effects that led to the administration of estrogen patches.

“I lost 25 pounds after half a year unintentionally. I lost the ability to eat any food in the morning as I would become sick right after I woke up, forcing me to get up and vomit… I began a tiny half patch dose of estrogen alongside the Lupron after two months, but it did almost nothing to prevent the side effects… after a year, my [endocrinologist] upped my dose of estrogen to a full mini patch, which I am still on… in my experience, puberty blockers are a bad idea without a solid dose of [hormone replacement therapy].”

            Both teenagers went through their natal puberty before starting puberty blockers, which means they already expressed most secondary sex characteristics that cannot be changed. But there is no need for an adolescent who has already experienced puberty to be put on puberty blockers. The big changes like bone structure and voice deepening have already occurred, and there should not be a pressure to disrupt the healthy processes like bone development just to stop any estrogen or testosterone from being released. These adolescents didn’t need to pause a puberty they had already gone through, and the blockers only caused them harm.

But even when puberty blockers are administered before puberty starts and the intended halted physical development is achieved, it’s not always the right decision. According to one study, there are young people with “severe and persistent gender dysphoria” who start puberty blockers hoping to find relief from their distress, but the treatment “had no significant effect on their psychological function, thoughts of self-harm, or body image” (Dyer). This is a compelling argument for the idea that gender dysphoria should not always be treated with medical intervention in children and adolescents.

Even if all the right steps are taken in a timely manner for a child with gender dysphoria, a gender transition is not always the answer. The child might not be struggling with being born in the wrong body, but rather dealing with sexual identity, abuse, an eating disorder, or a plethora of other things that should be explored and addressed long before puberty blockers are considered. In fact, the right decision might not be to administer puberty blockers to any child, instead letting them make the decision for themselves when they reach adulthood and have more time to explore their place in the world before committing to a big medical intervention that will change their body forever.

The physical and psychological ramifications of undergoing a gender transition are enormous and stressful, and real children are being spoken about in this paper. But with all the possible complications, and the risks that are yet to be discovered, I believe it is irresponsible to allow children to make a lifelong decision at such a young age when the effects are still largely unknown. As one study pointed out, “asking a child or adolescent to make a decision on whether they wish to put at risk their fertility, their genital development, their capacity for full sexual function and their brain development, in a context of an expressed need to resolve their immediate distress is… ethically problematic” (Pilgrim and Entwistle).

So, what’s worse? Dysphoric youth who identify as transgender into adulthood wishing they had transitioned sooner, or adolescents that were given puberty blockers growing older and living with regret over medical decisions that were made for them?

Works Cited

Ault, Alicia. “Transgender Docs Warn About Gender-Affirmative Care for Youth.” WebMD.com. Published 29 November 2021. https://www.webmd.com/sex-relationships/news/20211129/transgender-docs-gender-affirmative-care-youth#:~:text=Puberty%20blockers%20prevent%20genital%20tissue,neo%2Dvagina'%20from%20it%2C. Accessed 28 March 2022.

Barendse, Marjolein E. A., et al. “Your Brain on Puberty.” Kids.frontiersin.org. Published 30 April 2020. https://kids.frontiersin.org/articles/10.3389/frym.2020.00053#:~:text=However%2C%20researchers%20have%20discovered%20that,for%20new%20forms%20of%20learning. Accessed 28 March 2022.

BBC. “Keira Bell case: What are puberty blockers?” BBC.com. Published 12 October 2021. https://www.bbc.com/news/health-51034461#:~:text=%22Although%20Gids%20advises%20this%20is,%2C%20fatigue%20and%20mood%20alterations.%22. Accessed 28 March 2022.

Brunskell-Evans, Heather, and Michele Moore. Inventing Transgender Children and Young People. E-book, Cambridge Scholars Publisher, 2019. Accessed 11 May 2022.

Carmichael, Polly, et al. “Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK.” 2021. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0243894. Accessed 28 March 2022.

Compton, Julie. “Transgender fertility study sheds light on testosterone's impact.” NBCnews.com. Published 14 April 2020. https://www.nbcnews.com/feature/nbc-out/transgender-fertility-study-sheds-light-testosterone-s-impact-n1182636. Accessed 28 March 2022.

Dyer, Clare. “Puberty blockers do not alleviate negative thoughts in children with gender dysphoria, finds study.” BMJ, 2021. https://www.bmj.com/content/372/bmj.n356. Accessed 4 April 2022.

Economist. “Opinion on the use of puberty blockers in America is turning.” Economist.com. Published 16 October 2021. https://www.economist.com/united-states/2021/10/16/opinion-on-the-use-of-puberty-blockers-in-america-is-turning. Accessed 28 March 2022.

Giordano, Simona. “Importance of being persistent. Should transgender children be allowed to transition socially?” Journal of Medical Ethics, vol. 45, iss. 10, 2019, p. 654. https://www.proquest.com/docview/2305734792?accountid=14593&parentSessionId=Th1asEMx0V8xaBW3Wu4sFFDLO1QmBccukYQIgU8tK%2Fg%3D&pq-origsite=primo. Accessed 28 March 2022.

Grant, Ferguson, et al. “Gender dysphoria: puberty blockers and loss of bone mineral density.” BMJ: British Medical Journal (Online), vol. 367, 2019. https://www.proquest.com/docview/2347510105/fulltextPDF/38F8D0C58097415APQ/1?accountid=14593. Accessed 28 March 2022.

Lee, Janet Y., et al. “Low Bone Mineral Density in Early Pubertal Transgender/Gender Diverse Youth: Findings From the Trans Youth Care Study.” Journal of the Edocrine Society, vol. 4, iss. 9, 2020. https://www.proquest.com/docview/2436876205/732A087EC0764B4DPQ/11?accountid=14593. Accessed 28 March 2022.

Mayo Clinic Staff. “Children and gender identity: Supporting your child.” MayoClinic. Published 23 February 2022. https://www.mayoclinic.org/healthy-lifestyle/childrens-health/in-depth/children-and-gender-identity/art-20266811. Accessed 28 March 2022.

Palmert, Mark R., and Leo Dunkell. “Delayed Puberty.” The New England Journal of Medicine, vol. 366, iss. 5, 2012, pp. 443-453. https://www.proquest.com/docview/919684282?accountid=14593&parentSessionId=TKCZrKk5op5AjukRR%2BAC5Q8X3%2Fze96zRJFDs1u%2BrzuI%3D&rfr_id=info%3Axri%2Fsid%3Aprimo. Accessed 28 March 2022.

Peper, Jiska S., and Ronald E. Dahl. “The Teenage Brain: Surging Hormones—Brain-Behavior Interactions During Puberty.” Current Directions in Psychological Science, vol. 22, iss. 2, 2013, pp. 134-139. https://journals-sagepub-com.weblib.lib.umt.edu:2443/doi/full/10.1177/0963721412473755. Accessed 28 March 2022.

Pilgrim, David, and Kirsty Entwistle. “GnRHa (‘Puberty Blockers’) and Cross Sex Hormones for Children and Adolescents: Informed Consent, Personhood and Freedom of Expression.” The New Bioethics, vol. 26, iss. 3, pp. 224-237. https://www-tandfonline-com.weblib.lib.umt.edu:2443/doi/full/10.1080/20502877.2020.1796257. Accessed 28 March 2022.

Saggese, Giuseppe, et al. “Puberty and bone development.” Best practice & research. Clinical endocrinology & metabolism, vol. 16, iss. 1, 2002, pp. 53-64. https://pubmed.ncbi.nlm.nih.gov/11987898/. Accessed 28 March 2022.

Shrier, Abigail. “Top Trans Doctors Blow the Whistle on ‘Sloppy’ Care.” Common Sense. Published 4 October 2021.

Top Trans Doctors Blow the Whistle on ‘Sloppy’ Care

Accessed 4 April 2022.

St. Louis Children’s Hospital. “Puberty Blockers.” StLouisChildrens.org. https://www.stlouischildrens.org/conditions-treatments/transgender-center/puberty-blockers. Accessed 28 March 2022.