The Truth about 'Puberty Blockers'

A recent Washington Post article asserts that the effects of administration of puberty blockers (GnRHa) to minors presenting with gender dysphoria (GD) are “reversible.”  In support, the Post cites an American Academy of Pediatrics (AAP) Policy Statement.  However, public sources and even the Policy Statement itself disclose information belying reversibility.  The AAP Policy Statement states: “…reversibility is based on the little data that are currently available.”   A report of an American Psychiatric Association (APA) Task Force clarifies there is not just an issue of little available data, but, rather, it is a complete lack of randomized controlled treatment outcome studies, and that is one reason why there is “no consensus” regarding treatment of children presenting with GD and why “opinions vary widely among experts” as to treatments.   The policy statement further admits: “The effect of sustained puberty suppression on fertility is unknown.”

Bioethicist Michael Cook reports that, according to Nature magazine, only in 2017 did the National Institutes of Health launch the “first” prospective study “to examine the effects of drugs that block puberty until a teenager’s body and mind is mature enough to begin cross-sex hormone treatment.”  The study (per the grant application) “will be the first in the U.S. to evaluate longitudinal outcomes of medical treatment for transgender youth and will provide essential evidence-based data on the physiological and psychosocial effects and safety of treatments currently used for transgender youth.”

Given that there are and have been no randomized longitudinal treatment outcome studies and the AAP admits that the effect of suppression on fertility is “unknown,” there can be no credible claim that use of puberty blockers is either a safe or reversible treatment for children presenting with GD.

Information from the U.K. reveals actual evidence as to physical harm and ethical issues arising from administration of puberty blockers.  In 2011 the Tavistock and Portman NHS Trust (Tavistock) started an experimental treatment program for minors presenting with GD using puberty blockers.  Many professionals were and are opposed to the program.  After continued program noncompliance with requirements to provide detailed outcome reports, many have sought to determine the results of the program, even to the point of filing a Freedom of Information demand.  Oxford Professor Michael Biggs reviewed a 2019 report from the government oversight Health Research Authority (HRA) related to its investigation into the experimental Tavistock program.  Biggs stated several observations after his review:  (a)  For a statistically valid and meaningful longitudinal study to result, it would be necessary to follow-up on outcomes for each participant into adulthood. That was not done because the consent forms signed by or on behalf of participants only permitted follow-up until age 16.  (b)  Tavistock “gave children and parents incomplete and misleading information, which contradicted the research proposal. Whether they could provide informed consent, in such circumstances, is open to serious question.”  (c)  Tavistock’s director admitted: “The blocker is said to be completely reversible, which is disingenuous because nothing’s completely reversible.”

The HRA itself concluded: “Researchers and clinical staff should consider carefully the terms they use in describing treatments e.g. avoid referring to puberty suppression as providing a ‘breathing space,’ to avoid risk of misunderstanding.”  In other words, parents and the public are on warning that puberty blockers should not be represented or considered to be ‘reversible’ and do not result in a mere ‘pause’ or ‘time to decide’ or ‘breathing space to explore options’. 

Biggs described additional negative outcomes of the Tavistock program which he gleaned from documents from Tavistock or its endocrinologist:

1. “…there was no overall improvement in mood or psychological wellbeing using standardized psychological measures.”

2. “Natal girls showed an increase in internalising problems from t0 to t1 [after 12 months on GnRHa] as reported by their parents.”

3. After a year on GnRHa, “a significant increase was found in the first item “I deliberately try to hurt or kill self”.

4. “Partial suppression [of sex hormones by GnRHa] may produce more side effects due to hormone swings, and also a lowering in mood leading to clinical depression. Expectations of improvement in functioning and relief of the dysphoria are not as extensive as anticipated, and psychometric indices do not always improve nor does the prevalence of measures of disturbance such as deliberate self-harm improve.”

Finally, Biggs refers to a recent article (Tobin, Ting, and Butler 2018) cited by Tavistock, emphasizing that bone density did not decline, in absolute terms, after GnRHa was administered, misleading the reader because growing children need bone density to increase. The article did admit that the children did experience a decline relative to the normal standard for their age group, a decline especially marked for girls. Biggs graphed the actual distributions implied by the article’s figures:

A critical prerequisite for dispensing of medical and psychiatric advice and treatment (including puberty blockers) is the securing of “informed consent” from all children presenting with GD (and/or their authorized parents or guardians).  Examination of two publicly available informed consent forms (Childrens and Fenway) reveals that such forms may be inadequate, misleading, or outright false.  Missing is the information described above and disclosure of other material adverse medical, social, and economic risks and consequences, both of treatment and of transition, such as (a) findings in a review of 88 studies that an estimated 31.0% of transgenders (37.9% for trans women and 13.1% for trans men) are engaged in the sex trade, (b)  meta-analysis estimates that “a quarter (22-28%) of transgender women are living with HIV, and more than half (an estimated 56%) of black/African American transgender women are living with HIV,” and (c) findings in a 2018 study that 87.5% of participants (almost all of the heterosexual participants) would not consider a dating relationship with a transgender.                                                                          

Given the lack of proper longitudinal treatment outcome studies and the discovery of adverse treatment results at Tavistock, one must conclude that administration of puberty blockers to children presenting with GD is unwise, unsafe, and should not be represented as “reversible.”  Further, the deficiencies in the Tavistock study are strong warnings that an unbiased oversight committee should provide continuing detailed review of the protocols, procedures, and practices of the U.S. study so that unbiased managers (who have no vested interest in the promotion of GnRHa) are appointed, appropriate requirements (including the securing of informed consent and the inclusion of a control group not receiving the drug) are implemented, proper periodic reports are filed, and the purposes of the study are fulfilled.           

A recent Washington Post article asserts that the effects of administration of puberty blockers (GnRHa) to minors presenting with gender dysphoria (GD) are “reversible.”  In support, the Post cites an American Academy of Pediatrics (AAP) Policy Statement.  However, public sources and even the Policy Statement itself disclose information belying reversibility.  The AAP Policy Statement states: “…reversibility is based on the little data that are currently available.”   A report of an American Psychiatric Association (APA) Task Force clarifies there is not just an issue of little available data, but, rather, it is a complete lack of randomized controlled treatment outcome studies, and that is one reason why there is “no consensus” regarding treatment of children presenting with GD and why “opinions vary widely among experts” as to treatments.   The policy statement further admits: “The effect of sustained puberty suppression on fertility is unknown.”

Bioethicist Michael Cook reports that, according to Nature magazine, only in 2017 did the National Institutes of Health launch the “first” prospective study “to examine the effects of drugs that block puberty until a teenager’s body and mind is mature enough to begin cross-sex hormone treatment.”  The study (per the grant application) “will be the first in the U.S. to evaluate longitudinal outcomes of medical treatment for transgender youth and will provide essential evidence-based data on the physiological and psychosocial effects and safety of treatments currently used for transgender youth.”

Given that there are and have been no randomized longitudinal treatment outcome studies and the AAP admits that the effect of suppression on fertility is “unknown,” there can be no credible claim that use of puberty blockers is either a safe or reversible treatment for children presenting with GD.

Information from the U.K. reveals actual evidence as to physical harm and ethical issues arising from administration of puberty blockers.  In 2011 the Tavistock and Portman NHS Trust (Tavistock) started an experimental treatment program for minors presenting with GD using puberty blockers.  Many professionals were and are opposed to the program.  After continued program noncompliance with requirements to provide detailed outcome reports, many have sought to determine the results of the program, even to the point of filing a Freedom of Information demand.  Oxford Professor Michael Biggs reviewed a 2019 report from the government oversight Health Research Authority (HRA) related to its investigation into the experimental Tavistock program.  Biggs stated several observations after his review:  (a)  For a statistically valid and meaningful longitudinal study to result, it would be necessary to follow-up on outcomes for each participant into adulthood. That was not done because the consent forms signed by or on behalf of participants only permitted follow-up until age 16.  (b)  Tavistock “gave children and parents incomplete and misleading information, which contradicted the research proposal. Whether they could provide informed consent, in such circumstances, is open to serious question.”  (c)  Tavistock’s director admitted: “The blocker is said to be completely reversible, which is disingenuous because nothing’s completely reversible.”

The HRA itself concluded: “Researchers and clinical staff should consider carefully the terms they use in describing treatments e.g. avoid referring to puberty suppression as providing a ‘breathing space,’ to avoid risk of misunderstanding.”  In other words, parents and the public are on warning that puberty blockers should not be represented or considered to be ‘reversible’ and do not result in a mere ‘pause’ or ‘time to decide’ or ‘breathing space to explore options’. 

Biggs described additional negative outcomes of the Tavistock program which he gleaned from documents from Tavistock or its endocrinologist:

1. “…there was no overall improvement in mood or psychological wellbeing using standardized psychological measures.”

2. “Natal girls showed an increase in internalising problems from t0 to t1 [after 12 months on GnRHa] as reported by their parents.”

3. After a year on GnRHa, “a significant increase was found in the first item “I deliberately try to hurt or kill self”.

4. “Partial suppression [of sex hormones by GnRHa] may produce more side effects due to hormone swings, and also a lowering in mood leading to clinical depression. Expectations of improvement in functioning and relief of the dysphoria are not as extensive as anticipated, and psychometric indices do not always improve nor does the prevalence of measures of disturbance such as deliberate self-harm improve.”

Finally, Biggs refers to a recent article (Tobin, Ting, and Butler 2018) cited by Tavistock, emphasizing that bone density did not decline, in absolute terms, after GnRHa was administered, misleading the reader because growing children need bone density to increase. The article did admit that the children did experience a decline relative to the normal standard for their age group, a decline especially marked for girls. Biggs graphed the actual distributions implied by the article’s figures:

A critical prerequisite for dispensing of medical and psychiatric advice and treatment (including puberty blockers) is the securing of “informed consent” from all children presenting with GD (and/or their authorized parents or guardians).  Examination of two publicly available informed consent forms (Childrens and Fenway) reveals that such forms may be inadequate, misleading, or outright false.  Missing is the information described above and disclosure of other material adverse medical, social, and economic risks and consequences, both of treatment and of transition, such as (a) findings in a review of 88 studies that an estimated 31.0% of transgenders (37.9% for trans women and 13.1% for trans men) are engaged in the sex trade, (b)  meta-analysis estimates that “a quarter (22-28%) of transgender women are living with HIV, and more than half (an estimated 56%) of black/African American transgender women are living with HIV,” and (c) findings in a 2018 study that 87.5% of participants (almost all of the heterosexual participants) would not consider a dating relationship with a transgender.                                                                          

Given the lack of proper longitudinal treatment outcome studies and the discovery of adverse treatment results at Tavistock, one must conclude that administration of puberty blockers to children presenting with GD is unwise, unsafe, and should not be represented as “reversible.”  Further, the deficiencies in the Tavistock study are strong warnings that an unbiased oversight committee should provide continuing detailed review of the protocols, procedures, and practices of the U.S. study so that unbiased managers (who have no vested interest in the promotion of GnRHa) are appointed, appropriate requirements (including the securing of informed consent and the inclusion of a control group not receiving the drug) are implemented, proper periodic reports are filed, and the purposes of the study are fulfilled.