The Tea on Puberty Blockers

Part 1 of the actual science of affirming care for trans children

More than 1 in 3 trans youth in the United States live in states that have banned puberty blockers for trans minors, according to estimates by the Williams Institute. Bans have been pushed through on the heels of misinformation, particularly around the science behind puberty blockers. Earlier this month, Dr. Hillary Cass attempted to pass this misinformation as truth in a report for the United Kingdom’s National Health Service (NHS). While Dr. Cass has since tried to walk back her report’s claims, puberty blockers are no longer being prescribed by NHS clinics in England nor by the only gender identity clinic in Scotland.

The information environment is so poor that the American Psychological Association issued a statement on the strong evidential basis for gender affirming care for trans youth and adults. In truth, since the 1980’s the class of medications colloquially known as puberty blockers have been used prevent early puberties in cis adolescents. In 1993, they were approved by the FDA for this usage. In 1996, Dutch psychologists published a report on using puberty blockers as a treatment for children with gender dysphoria, and two years later they published a case study of a trans person who received puberty blockers from ages 13-18 before beginning masculinizing hormones at age 18. In their case study, the psychologists reported that by age 20, their patient was happy with his life and “never felt any regrets” for his medical transition.

This is of course a single example. But from 2017-2021, at least 4,780 adolescents in the United States started puberty blockers. Studies suggest that trans youth taking puberty blockers have improved quality of life compared to before starting the medication. No major side effects have been reported, and the medicines are completely reversible.

debunking the misinformation

Let’s start by debunking the most common arguments against puberty blockers:

• The use of puberty blockers to treat gender dysphoria is experimental. Puberty blockers have been used in medical settings to treat gender dysphoria for 30+ years, originated by the Dutch psychologists mentioned above. This is far from experimental.

• There is a lack of evidence that puberty blockers are safe. Puberty blockers have been FDA approved since 1993 for the treatment of an early puberty. FDA approval requires evidence of safety. Even after a drug has been approved, the FDA monitors reports of adverse effects in case anything was missed during initial safety trials. For transparency, the FDA makes summaries of these events publicly available. The dashboard indicates that the 5 major puberty blockers have a total 54 reported adverse events in 12-17 year olds with the first report of an adverse event in 2016 (23 years after initial approval). For comparison, 12-17 year olds have reported 5,319 adverse events for ibuprofen (Advil) and 270 adverse events for Adderall. So, there is not evidence that puberty blockers are unsafe.

• There is a lack of evidence that puberty blockers provide benefits for trans youth. A 2022 study followed trans youth before and after starting puberty blockers and/or HRT. This allows them to directly compare mental health states of each youth throughout the course of their care. This analysis found that affirming care resulted in 60% lower odds of depression and 73% lower odds of suicidality. Similar findings were reported in a 2020 study on a cohort of trans youth receiving puberty blockers, demonstrating decreases in depression and suicidality over time concomitant with an increase in quality of life. Further, a systematic review published in 2020 of 11 studies of trans youth taking puberty blockers also identified strong mental health benefits. While many anti-trans activists will point to a lack of randomized controlled trials, the methodology of tracking individuals over time and observing aggregate improvements in mental health is compelling evidence that puberty blockers provide tangible benefits for trans youth. And if you don’t believe me, believe the APA.

what’s a puberty, anyway?

Let’s take a step back and examine the science behind puberty blockers (and therefore puberty itself). As humans, we mainly consider puberty only by the effects it has on the body. We, of course, live in our bodies and experience our bodies changing in ways that we cannot control on our own.

At the biochemical level, puberty is coordinated by a series of hormones, called a cascade because of how one hormone can activate another which then activates a third hormone and so on. The word cascade evokes water falling down multiple steps where it gains energy so that the ultimate force of the water down the slope is unstoppable. You can think of hormone cascades in the same way - each new hormone pushing out more hormones toward the ultimate bodily goal.

When considering puberty, the final hormones involved in the cascade (and the ones that execute the bodily changes that we associate with puberty) are estrogens and androgens. Whichever your body is exposed to will largely dictate the specific characteristics that are affected.

Estrogen and Testosterone

The sum total of the hormonal cascade that drives puberty is called the hypothalamic-pituitary-gonadal axis. The initial hormones in this cascade are the same for all of us - regardless of sex assigned at birth. It begins in a small brain region called the hypothalamus which is responsible for coordinating many basic bodily functions such as body temperature, sleep, and eating. During puberty, the hypothalamus begins producing a hormone called gonadotropin-releasing hormone, or GnRH. GnRH production occurs in small bursts which over time is sufficient for the hormone cascade that drives puberty to reach full force.

GnRH travels a short distance through the blood to the pituitary gland, a neighbor to the hypothalamus. In the pituitary, bursts of GnRH cause the release of two new hormones: follicle-stimulating hormone (FSH) and luteinizing hormone (LH). FSH and LH are dumped into the blood and have a much longer route to travel. Eventually, they end up in the gonads, a convenient sex-neutral term to describe reproductive glands (testicles or ovaries). FSH and LH work together to promote the production of the sex hormones as well as the maturation of eggs or sperm.

puberty blocking medications (aka GnRH agonists)

Puberty blockers work to block the hormonal cascade of the hypothalamic-pituitary-gonadal axis at the highest level. If we extend the metaphor of hormones as cascade of water, puberty blockers are a dam that prevent the continuous flow of a river across decreasing elevations.

Most puberty blockers are “GnRH agonists” that mimic the hormone GnRH to exacerbate its biological effects. However, this presents of conundrum: If GnRH ultimately promotes the production of sex hormones (and therefore puberty), why do GnRH agonists (which mimic GnRH) suppress puberty?

The key to answering this question lies in the dynamics of GnRH. As mentioned earlier, GnRH is released by the hypothalamus in bursts rather than continuously. This means that the pituitary releases LH and FSH in bursts too. When someone is taking a GnRH agonist, however, there is constant stimulation of the pituitary. The pituitary becomes overwhelmed by the continuous stimulation and responds by shutting down production of LH and FSH altogether. (As a neurodivergent person, I can relate to the idea of shutting down after overstimulation.)

It’s important to note that this shutting down of the pituitary is reversible. If someone stops taking a GnRH agonist, then the pituitary is able to reset and begin responding to GnRH bursts once again. (In the same way, laying down in the dark helps me recover from overstimulation.) When this happens, LH and FSH are produced normally, and the hormonal cascade that drives puberty resumes.

what are state governments actually banning?

Today, 23 states in the United States have banned puberty blockers for trans youth. But what does that actually mean? Can no one - even cis people experiencing early puberties - access puberty blockers? The answer is no. All 23 states¹ that have banned puberty blockers allow an exception for cis folks exhibiting early puberties and for people with a “disorder of sex development.” Many states define that second term to refer to intersex individuals, likely to continue to the harmful practice of unnecessary surgeries on intersex newborns. The language for this exception is strikingly similar from state to state because conservative groups have been providing states with template anti-trans legislation.

Tellingly, four states (Kentucky, South Dakota, Idaho, and Wyoming) ban any medication prescribed with the intent to delay puberty. Despite grandstanding about standards of evidence and (nonexistent) safety concerns, policymakers are primarily targeting the idea of gender affirming care and secondarily the specific medications and procedures that make up affirming care.

This calls to mind the work of historian Jules Gill-Peterson who argues in Histories of the Transgender Child that children represent a metaphor, albeit one steeped in racism and eugenics,² for biological plasticity (the potentiality of the body to take one of many possible forms):

Since plasticity is a quality — a capacity to generate and receive imprints of form — and not a visibly discrete “part” of the body, endocrinology called upon the figure of the developing child to serve as a stabilizing metaphor. As a metaphor for an invisible but material plasticity, the child organized sex and growth along parallel phylogenetic and ontogenetic scales.

Despite this metaphor’s past as a stabilizing force for the biological concept of plasticity, today the transgender child and their plasticity undermine conservative gender ideologies. Therefore, legislation targeting children’s access to affirming care attempts to politically undermine the scientific foundation of affirming care for transgender folks regardless of age.

The abstracted nature of legislative assaults on trans youth begs the question: Will they get away with it? In the United States, the judicial system is working through this question with mixed results. It is ultimately likely that the Supreme Court will have to make that determination. The legal standard for laws like affirming care bans is whether the care is “deeply rooted in the nation’s history and traditions.” This once-dead legal test was revived by the Supreme Court in Dobbs v. Jackson Women’s Health Organization for the purposes of stripping nationwide access to abortion health care.

To be clear, affirming care for youth is “deeply rooted in the nation’s history and traditions.” In her book, Gill-Peterson details trans and intersex youth (and their families) seeking affirming medical interventions as early as the 1920’s. (Although doctors turned many potential patients were turned away, particularly patients of color.) Further, the Supreme Court itself affirmed in its 2000 decision Troxel v. Granville that a parent’s right to direct health care for their child is “perhaps the oldest of the fundamental liberty interests recognized by this Court.” (We should, of course, acknowledge the infantilizing nature of this argument which merely reducing children to legal extensions of their parents. Drawing from the work of Paul Amar, Gill-Peterson reminds us that “the child is a dehumanized social form, the product of historical and political processes of infantilization ‘designed to control various populations’ through sexual and racial difference, rather than to index meaningful age differences.”)

Regardless, youth seeking affirming care largely do so with parental consent, meaning an extension of Troxel satisfies the “history and tradition test” in defense of trans youth. Yet, the intentional ambiguity of the test leaves room for subjective interpretations within the judiciary.

And unfortunately, last week the Supreme Court permitted Idaho’s enforcement of its ban on affirming care for trans youth (save for the two anonymous trans plaintiffs). While the justices seemingly are concerned about legal technicalities rather than the constitutionality of Idaho’s law, their dodging means that nearly 1,000 trans youth in Idaho will be unable to access affirming care. Once gain, political infantilization has reduced living children to a mere abstraction - this time for an esoteric legal concept.

1. Yes, I read all of the laws so that you don’t have to.

2. The realities of which we will return to in the future at QSL. But for now, I will recommend Gill-Peterson’s book which details the way this metaphor led to dehumanizing experimentation on the bodies of intersex youth and the marginalization of intersex youth of color.