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Delaying Puberty, or Destroying It?

Photo credit: Delia Giandeini on Unsplash.

Author’s note: This is Part Five of a seven-part series about transgenderism. Nothing in the series is intended to disparage any transgender person, any gender non-conforming person, or any person attracted to members of the same sex. I write as a developmental biologist (Berkeley PhD), and I focus on evidence pertaining to transgender treatments for children.

WARNING: Parts of this series contain explicit language. Reader discretion is advised.

A gonadotrophin-releasing hormone analog (GrNHa) is a “puberty blocker.” In Part Four I pointed out that puberty blockers are used to treat precocious puberty. In those cases, puberty starts well before the age of eight in girls or the age of nine in boys. When the blockers are stopped, normal puberty resumes. In other words, puberty blockers are fully reversible when used to treat precocious puberty.

Part Four also described an experiment in which healthy children with short stature were given puberty blockers. The children were receiving growth hormone, but puberty reduces its effect. Three dozen children who had started puberty early (though not precociously) were given puberty blockers to extend the effect of growth hormone. The treatment was stopped after three years, and normal puberty resumed. So puberty blockers are completely reversible when administered for a limited time to normal, healthy children in early puberty. 

What about puberty blockers used to treat gender dysphoria?

According to transgender advocates, “The suppression of puberty using GnRHa is a reversible phase of treatment.” Thus “it can be considered as ‘buying time’ to allow for an open exploration of the SR [sex reassignment] wish.” In 2017 the Endocrine Society claimed that “the best available evidence” supported this treatment.

What Is the Evidence?

Those who start “transitioning” to the other sex may “persist” or “desist.” Persisters go on to transition. Desisters choose to stop and accept their biological sex. A 2013 article cited studies of 246 children with gender dysphoria. Of those, 207 desisted before being treated with puberty blockers. The same article reported a more recent study of 127 children. Of those, 80 chose not to begin puberty blockers. So 287 (77 percent) of 373 children desisted before treatment. Reversibility was not an issue for them.

What about after starting treatment? A 2018 study at the Vrije Universiteit Amsterdam reported 333 adolescents who started on puberty blockers. All except 6 (1.9 percent) went on to take cross-sex hormones. The study did not report the ages at which the 6 desisted. Were they still within the normal range of puberty onset? What were their lives like afterwards? We simply don’t know.

A More Recent Study

2020 study looked at 269 children and adolescents registered at the Curium-Leiden University gender clinic in the Netherlands. Of these, 143 (38 boys and 105 girls) started treatment with GnRHa. The youngest boy to start was 11. The youngest girl was 10. Of the original 143, 125 (87 percent) later moved directly from GnRHa to cross-sex hormones.

According to the study, the high rate of persisters might have been “due to eligibility criteria that select those highly likely to pursue further gender-affirming treatment.” The authors also noted that “due to the observational character of the study, it is not possible to say if GnRHa treatment itself influenced the outcome.” 

The 2020 study did follow up on those who did not move directly from GnRHa to cross-sex hormones. Most of them were not really desisters. Instead, they pursued alternate routes to transition. Only five (4 girls and 1 boy) no longer wanted cross-sex treatment. Combining the numbers from 2018 and 2020, there were 11 desisters out of 476 children who started on puberty blockers (about 2 percent).

Why is the rate of desistence among those who start on puberty blockers so much smaller than those who never started — 2 percent versus 77 percent? Perhaps it has to do with the selective effect of “eligibility criteria,” as the Leiden report suggested. Perhaps it has to do with the transgender-supportive counseling received by children undergoing puberty suppression for gender dysphoria. 

Or perhaps it has to do with the social effects of delaying normal development. Imagine being a 16-year-old boy with the voice and genitals of an 11-year-old. Or being a 16-year-old girl with no breasts or pubic hair. Would you prefer to hang out with a transgender-friendly peer-support group? Or would you choose to rejoin your non-transgendering contemporaries? 

A Point of No Return?

Given the lack of evidence, British pediatrician Christopher Richards and two others wrote in 2019 that puberty blockers for gender dysphoric children are a “momentous step in the dark.” Since almost all children who start on them go on to take cross-sex hormones, it seems that the “completely reversible” claim is exaggerated.

Critics argue that children below the age of 18 are not capable of making life-transforming decisions. But even if they are, it is misleading to tell them that puberty blockers are just “buying time” for them to explore their gender identity. It would be far more truthful to tell them — and their parents — something like the following:

“We can give you medicine that will block changes in puberty that you might find disturbing. According to the evidence, if you don’t take the medicine there is at least a three out of four chance that you will grow up happy with the body you have. On the other hand, once you start taking the medicine there is a 98 percent chance that you will go on to take cross-sex hormones. Those hormones will probably make you sterile, and you may have to take them for the rest of your life.”

In October 2020, a British High Court agreed that “the vast majority” of children receiving puberty blockers “proceed to the use of cross-sex hormones.” These have “potential life changing consequences for a child.” So “it is highly unlikely that a child aged 13 or under would be competent to give consent.” It is also “doubtful that a child aged 14 or 15 could understand and weigh the long-term risks and consequences.” The British National Health Service immediately stopped offering puberty blockers to children under 16.

The bottom line is that, in practice, puberty blockers do not delay the momentous decision to transition to the other sex. In almost every case, they are the momentous decision. For children with gender dysphoria, blocking puberty is not just buying time. It is more like a point of no return.