Home Gender & Sexuality Puberty Blockers Are Not a Good Idea for Treating Gender Dysphoria – Here’s Why

Puberty Blockers Are Not a Good Idea for Treating Gender Dysphoria – Here’s Why

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Puberty blockers are medications that are used to delay puberty in children, typically gonadotropin-releasing hormone (GnRH) agonists, which stop the body from producing sex hormones, particularly testosterone and oestrogen.

One of the best-known of these medications is sold under the brand name Lupron. Originally developed to treat children going through precocious puberty – when a child starts showing signs of puberty years before they should, with associated risks for their health and development – in more recent years, they have also been diagnosed in some children experiencing gender dysphoria, when the person feels that their biological sex does not match their individual feelings of gender, and when these feelings are both strong and persistent over time. The same medications are sometimes used to treat adults for various health conditions and occasionally to reduce the sex drive in habitual male sex offenders.

What is the impact of puberty blockers on the body?

Puberty blockers have various effects on the body. Firstly, in children, they halt the development of secondary sex characteristics, such as breasts and facial hair, which can be very distressing to young people going through unwanted puberty. Secondly, they also have a cascade of effects on the developing body, some of which are not yet fully understood, including impacts on bone density and brain development.

While children will resume puberty when they cease taking the blockers, some of these effects can be permanent and may include infertility, loss of sexual function, underdeveloped genitals, and changes to brain function. For children born male who may wish to have a vaginoplasty – the creation of an artificial vagina – in later life, it is possible that their male genitalia will not reach sufficient size to carry out this procedure successfully, as it typically involves the inversion of a penis. Children can also experience significant side effects while taking puberty blockers, including hot flushes and mood changes.

What does the medical establishment think of puberty blockers?

Globally, attitudes towards the use of puberty blockers are varied, but concern is growing. In March 2024, the British government announced that the NHS (the National Health Service) will no longer routinely prescribe puberty blockers to children experiencing gender dysphoria, but will instead provide alternative therapies. Elsewhere in Europe, many other countries – including Finland, France, Sweden and Norway – have adopted a precautionary approach to puberty blockers, citing substantial risks to children’s health and an overall lack of research into the long-term safety of their use.

There is great medical concern in particular relating to bone health, as young adults who were on puberty blockers as children and adolescents have been shown to have significantly reduced bone density, with respect to their as yet imperfectly understood implications for IQ and overall brain function. We do, however, know that the adolescent brain is not yet sufficiently developed to assess risk, and that adolescents in general struggle with understanding risk and making risk-informed decisions. 

Treatment modalities for children with gender dysphoria

Gender dysphoria is a very distressing condition and particularly difficult for children approaching puberty, who are dealing with the dramatic hormonal changes of all adolescents while also feeling uncomfortable with their physical reality, and deeply anxious about the changes that puberty is going to bring. 

It is, of course, essential to treat any child presenting with gender dysphoria with empathy, compassion, and respect. Parents and responsible carers want above all to alleviate the child’s distress, and it can be very tempting to provide a medication that will prevent, at least for now, an emotional crisis relating to the development of unwanted sexual characteristics. 

Proponents of puberty blockers describe them as offering a “pause button” that will give the child time to think about what they really want, with the implication that, if they come to terms with their physical selves, they can come off the blockers and resume puberty, but if they persist in expressing a deep desire to present as the other sex, then cross-sex hormones and, ultimately, surgery are available as options.

Unfortunately, in today’s medical climate, the whole issue of gender identity has become intensely politicised, with strong opinions on all sides. In this context, the role of any carer must be to do what is best for the child, and not to be swayed by ideological pressures. 

So, are puberty blockers really the answer?

Research suggests that, far from being a simple “pause button”, puberty blockers actually have a profound impact on whether or not children decide to progress onto cross sex hormones and other treatments to make them more closely resemble the opposite sex. In the case of children with gender dysphoria who are not prescribed blockers, typically about 80% come to terms with their physical bodies and do not continue to identify as transgender in adulthood. Conversely, the overwhelming majority of children who take puberty blockers for a prolonged period of time progress to cross-sex hormones subsequently, suggesting that many children in whom gender dysphoria would otherwise naturally resolve are actually getting locked in to what, in most cases, would be a temporary state of distress

It is often the case, particularly in boys, that a powerful sense of “really” being the other sex is indicative of future same-sex attraction, rather than a transgender identity per se. In other words, many young boys who experience gender dysphoria can grow up to be healthy, happy, and well-adjusted gay men. In general, young people who suffer from gender dysphoria are much more likely than average to start having feelings of same-sex attraction in adolescence.

With boys with gender dysphoria, it may be valuable to explore attitudes in the child’s family and broader community towards same-sex attraction. If they are regularly exposed to homophobic views, this may have led to them internalising anti-gay feelings that, as puberty approaches and a nascent sexuality starts to emerge, cause them deep distress. Deep down, these children may feel that it would be easier, and that they would be more accepted, if they were girls. It is relevant here to point out that in Iran, where homosexuality is illegal and severely punished, transgender identities – which are legal and officially accepted – are relatively high. 

Girls with gender dysphoria may also grow up to be same-sex attracted women. Girls approaching and going through puberty can also feel distress when they start to experience unwanted sexual attention or harassment. Girls of this age group are also particularly prone to what is known as social or peer contagion. Mental health conditions and associated behaviours, including eating disorders, self-harm, and trans identities, sometimes occur in clusters of friends at school, who empathise with one another to the point whereby they unconsciously start imitating one another and present with the same condition. Whereas in the past gender dysphoria was typically much more common among men and boys, in recent years there has been an extraordinary increase in the number of girls presenting with the condition; in the UK alone between 2009 and 2019, there was an increase in referrals from girls in adolescence of 5337%, with 76% of the patients at England’s Tavistock clinic being female by 2019. While, again, more research is required to explain this phenomenon, these astonishing figures are at the very least suggestive of the idea that a social contagion may be at least partly responsible, particularly as, in the current cultural climate, people of all ages are spending enormous amounts of time online, where virtual communities often seem to offer the affirmation and acceptance that may seem to be lacking in the real world. 

Gender dysphoria frequently presents with co-morbidities, with autism being common among children with this issue. In fact, children with gender dysphoria are many times more likely than the general population to also have an autism diagnosis, or to display symptoms of autism. While more research is required to understand why, it seems likely that young people with autism may struggle with nuanced views of gender expression. For example, a boy with autism who is sensitive, shy, and prone to tears may have acquired the idea that these are not traits associated with boys and men, and may therefore conclude that he is “really” a girl. This is just one of many reasons why there are reasons to doubt the ability of many of the children who present with gender dysphoria to consent to taking puberty blockers and the long-term impacts of their use.

In the case of both girls and boys with gender dysphoria, it is important to rule out prior or ongoing sexual abuse, or domestic or physical violence within the family, as these can contribute to a child’s lack of ease with his or her biological sex. 

Alternative approaches to puberty blockers

When a child or young person presents with debilitating gender dysphoria, it is of course essential to acknowledge and affirm their feelings, as it is with any mental health condition that is causing great distress. However, rather than rushing them onto medication that is known to have very significant side effects, a watchful waiting approach gives them time to explore their identity without medicating them. It may also be useful to explore with the family whether the child is growing up in an environment in which anti-gay feelings are expressed and to mitigate against this. 

It is essential to communicate with the child that there is no “right” way to be a boy or a girl. While certain behaviours – such as aggression or assertiveness in males, and timidity and conciliation in girls – are typically associated with one sex or the other, it is perfectly normal and healthy to be non-stereotypical. Children may feel relieved to hear a trusted adult assure them that there is nothing “wrong” with their personality type and that their sex does not have to determine their behaviour, tastes, or future sexual orientations. 

The evidence suggests that a full social transition – when the child changes his or her name and manner of dress to those typical of the opposite sex, and is introduced as the opposite sex – can actually embed feelings of dysphoria rather than relieve them. However, children can be encouraged to express their personalities through their clothing and toy choices, especially if they feel constrained by their sex to dress and play in ways they don’t like. 

In today’s environment, it can be very difficult for therapists to take a “watchful waiting” approach to children with gender dysphoria, as discussions of the condition have become an ideological battleground. At one end of the spectrum, extremists insist that any intervention short of full affirmation of a transgender identity, together with any pharmaceutical and surgical interventions the patient and their family demand, is a type of conversion therapy. On the other hand, families from conservative religious or other conservative backgrounds may pressure children to conform to extremely restrictive, stereotypical behaviours and appearances, or teach them that same-sex attraction is wrong and sinful. 

Children and young people who are suffering from gender dysphoria often fall between these two opposing camps. The role of their families, and of their therapists, is to truly listen to them, to provide them with a safe, comfortable space in which to explore their issues, and to reassure them that neither their bodies nor their personalities, nor their emerging sexualities are “wrong”.  It may also be useful to explore the psychosocial dynamics at play in the wider family and community, and the potential for therapeutic interventions with the parents may also be considered.

Dr Becky Spelman is a psychologist and founder of Private Therapy Clinic

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