The use of puberty blockers in gender transitioning adolescents. By Janet Spittlehouse, Kaden Russell and Sue Bagshaw

For some people, their innate sense of self does not fit with their biological sex. This experience is called gender dysphoria. Sometimes medications called ‘puberty blockers’ (Gonadotropin-releasing hormone analogues) are used to stop the production of reproductive hormones. They delay the onset of puberty, thereby preventing development of undesired secondary sex characteristics such as breasts, facial hair, and deepening of the voice. The primary aim of this treatment is to allow the adolescent more time to explore their gender identity without the stressors of puberty. However, this intervention is controversial. Those who advocate for the use of puberty blockers emphasise their benefits to mental health and their ability to reduce the necessity and complexity of certain medical procedures for those who choose to transition. Critics raise concerns about long-term adverse effects, particularly those on bone mineral density, brain maturation, and cardiovascular risk. Ethical debates around the ability of adolescents to consent to medical treatment, potential harms of the treatment, medicalisation of transgender individuals, and the experimental nature of puberty blocking treatment are the focus of much of this controversy.

We recently undertook a literature review of the peer reviewed published research in this area. We assessed the impacts of puberty blockers on psychosocial and physical health, as well as the ethical debates around this topic.

The psychosocial findings of the literature review were mostly positive: improvement in global functioning, improved management of comorbid mental conditions (particularly anxiety and depression), and reduction in suicidality. Gender dysphoria remained largely unchanged, which is attributed to the fact that puberty blockers do not remove unwanted features of an adolescents body, but rather prevent new unwanted features from developing.

The research on the physical impacts of puberty blockers is limited and evidence for long term outcomes are not yet available. The research indicates that there is a decrease in bone mineral density but that appears to normalise after puberty blockers are stopped and the new sex hormones are commenced (for those who choose to transition). There is a lack of evidence around the impacts of bone mineral density for those who do not receive new sex hormones. Cardiovascular risk appears to remain unchanged and the effects on brain maturation are still unclear.

The ethical concerns continue to be debated by experts but include the following key topics:

  • Whether adolescents have the ability to understand and consent to medical treatment  (legality varies by country). In New Zealand, the ability of adolescents to consent is up to clinician discretion to determine their capacity. In the UK, a recent ruling concluded that adolescents would not be able to consent to puberty blockers before the age of 16 years.
  • Whether this treatment should be considered experimental. The best way to get evidence about the benefits and harms of drugs is to carry out a Randomised Controlled Trial but this would be practically impossible for puberty blockers used for gender dysphoria. Because of this lack of research, some suggest that use of puberty blockers in gender dysphoric adolescents is experimental.
  • Whether more harm is caused by giving or withholding treatment. Supporters of the use of puberty blockers cite their benefits to psychosocial wellbeing, while critics cite the risk of reduced bone mineral density and infertility.
  • Whether this treatment prevents the resolution of gender dysphoria or influences adolescents to ‘become transgender’. Some critics suggest that puberty is essential to determine gender (though studies have not been conducted to show this), while others state that gender is determined before puberty.

Our conclusion is that the research shows the benefits of puberty blockers on mental and social wellbeing. Additionally, the research shows that many of the concerns about the use of puberty blockers are ethical (based on moral principles and beliefs), rather than physical.

Importantly, the review highlights the need for unbiased and stringent research. Gender dysphoric individuals are increasingly seeking medical treatment and high quality research is vital to provide optimal care.

* Kaden Russell will be presenting the results of this review at The Collaborative Trust Research seminar on Friday 26th February 12.30pm — 1.30pm. Click here for more information.

For a comprehensive review please see:

Mahfouda, S., Moore, J. K., Siafarikas, A., Zepf, F. D., & Lin, A. (2017). Puberty suppression in transgender children and adolescents. The Lancet Diabetes & Endocrinology, 5(10), 816-826 https://www.thelancet.com/journals/landia/article/PIIS2213-8587%2817%2930099-2/fulltext