November 14th marked the beginning of Trans Awareness Week, which the New York Times apparently decided to kick off with a commentary entitled They Paused Puberty, but is there a Cost? Megan Twohey and Christina Jewett. The article, touted as the end result of the reporters having spent “months scouring the scientific evidence, interviewing doctors around the world and speaking to patients and families,” focuses on gonadotropin-releasing hormone analogues (GnRHa)—known colloquially as puberty blockers—and their use in the gender-affirming care of transgender adolescents. These medications block the production of the sex hormones testosterone and estrogen, thereby delaying physical changes associated with puberty. The authors of the article express grave concern about using these medications to halt puberty in transgender and gender diverse (TGD) youth.
At the outset, we must reckon with the elephant in the room: This article is neither fair, balanced, nor expert in its coverage.
First, the paid review of the scientific literature featured in the article was conducted by an epidemiologist with no expertise in any medical field pertinent to trans health and no experience in clinical medicine whatsoever. While Dr. Farid Foroutan is indeed accomplished in his field, he appears to be unaware of important relevant context behind the findings he reviewed, which is not surprising given that a PubMed search shows that, prior to this NYT article, he has never published on the topics of transgender health or gender dysphoria. Rather, his primary area of expertise appears to be population studies of cardiac health and cardiology, particularly cardiac transplantation, which makes it rather odd to us that the NYT chose him to carry out this literature review. Even experts in research methods can be misled when they apply that expertise to topics outside of their usual areas of study. If the examples of John Ioannidis and Vinay Prasad’s writings about COVID-19 since the pandemic hit haven’t demonstrated this problem conclusively, we don’t know what will.
Second, and worse, the article is framed as a debate between Republican politicians with ideological agendas,supported by a handful of “detransitioners” with similar ideological goals, and gender-affirming doctors with science-based, research-grounded frameworks. The consequences are severe when mainstream media platforms launder transphobic talking points, and the NYT article has already been cited and praised by multiple gender-critical (GC) platforms. Yet, there is also a cost in that the scientific debates regarding the long-known risks of puberty blockers and how to manage and overcome them are muted to create this false frame. Actual discussions among qualified doctors that are relevant to parents of trans youth are either ignored or downplayed. The fearmongering is endless as conservative pundits, anti-LGBTQ activists, the GC movement, self-appointed “experts” who have never interacted with trans patients, and mainstream media outlets continue to promote conspiracy theories such as the one echoed here: “The doctors know how dangerous and experimental gender-affirming medicine is but downplay it or cover it up entirely!” Does this sort of claim sound familiar? It should, as we will discuss near the end.
Questionable Structure, Selective Focus, and Skewed Perspective
The authors begin with three anecdotes of patients who had all shared the experience of being treated with puberty blockers at one point. These anecdotes form the article’s frame around which discussion of the science and the ostensible “debate” over puberty blockers is structured. Yet, these anecdotes cannot be used responsibly to illustrate the full scope of the science. Here’s why.
One out of the three patients discussed has had a positive experience and is positioned in the article as evidence that puberty blockers can help trans youth, thus setting up the frame of benefit versus harm in a way that ends up emphasizing harm when the other anecdotes are discussed. For example, a second patient, an anonymous teen from New York is described as having gone off blockers after two years of an initially positive experience when it was discovered that the patient “had such a significant loss in bone density” and that during treatment, “the teen’s bone density plummeted — as much as 15 percent in some bones — from average levels to the range of osteoporosis.” The NYT notes that while the doctor recommended beginning testosterone, the parents had “lost faith” in the medical council and later quotes the parents as saying, “I don’t think we have the science behind them to be prescribing these drugs.” Yet, in describing this anecdote, the NYT fails to mention that, according to their own evidence that they hired Dr. Foroutan to review, such a reaction is nowhere near the typical response to puberty blockers. There is no evidence beyond the parents’ intuition that the puberty blockers caused bone density decline. Indeed, the available evidence is that they don’t normally do that according to the NYT’s own sources. “The change in bone density while adolescents were on blockers was observed to be zero,” according to the article.
Why, then, is this not mentioned when discussing this teen? The parents may blame the blocker, and indeed, the blockers may have played a role, but what happened in this patient that was different from the first? What might have been done either before or after this unnamed teen went on blockers to identify and minimize the risk? Again: the parents disregarded the advice of a doctor and made their own causal attributions. That isn’t a scientific approach to understanding risk. The article is correct that bone density is important when assessing any patient’s potential risks of taking puberty blockers. The problem is that it advances an intensely skewed and selective perspective on these risks.
In addition to the unnamed New York teen, the article discusses the case of a 15-year-old in Texas whose spinal bone density fell below the first percentile after “more than a year on blockers.” The authors reference an even more extreme example—a Swedish trans adolescent who developed osteoporosis and suffered a compression fracture that resulted in a lifelong disability, who was on puberty blockers for three years. However, the authors do not see fit to inform the reader that these are extreme cases that are very much atypical of youths treated with puberty blockers—cis or trans. One can’t help but make an analogy to the manner in which antivaccine activists cherry pick the most dramatic cases of “vaccine injury,” whether the injury was definitely caused by vaccines or not, in order to promote their agenda.
To their credit, the authors state that the risks of puberty blockers are heightened for youth who have bone problems before they go on blockers. They also explain that the Texan teenager had no preliminary bone scans and that the Swedish adolescent had no bone scans prior to the final year of treatment. However, the authors fail to explain that because of this lack of information, we cannot conclude that the puberty blockers caused the horrific effects reported. Given how extreme these effects are, there were almost certainly pre-existing factors that would have put the subjects at risk with or without the blockers. To a critical eye, these cases represent the need to increase the availability and affordability of routine bone mineral density scans throughout adolescent medical gender affirmation—not a cause to ban treatment for everyone.
It must also be noted that the example of the Swedish adolescent is not neutral and comes from a dubious source, specifically the documentary Transbarnen, the latest in a line of programs skeptical of trans medicineproduced by Swedish broadcast network SVT in a country that has deemed the risks of blockers to outweigh the benefits, citing detransition and uncertainty—rather than bone density—as factors for the decision. It is also worth noting that Drs. T’Sjoen and deVries—the latter quoted in the NYT article—have released an official EPATH statement distancing themselves from the documentary series. In light of this background, the inclusion of this example, without contextualization, strongly suggests biased reporting.
Why is this bias compromising? Let’s play Devil’s advocate and assume, for the moment, that it’s true that gender-affirming health care providers downplay or ignore the risks of puberty blockers. Let’s assume, for the moment, that this article honestly aims to inform parents of TGD youth and a general audience of these risks. One fundamental way to manage those risks would be to advocate for expanded, affordable, routine bone density screening to be standardized in care so that children at risk for these extreme outcomes can be readily identified. This is especially important because, consistent with prior studies, a cross-sectional analysis of the longitudinal, observational, prospective Trans Youth Care Study cohort notes a high prevalence of low BMD in early pubertal trans youth—before they start taking puberty blockers. Trans youth—particularly trans girls—often present low bone density at baseline due to lack of exercise, poor nutrition, and vitamin D deficiency. These factors have been speculated to result from their dysphoria (e.g., eating disorders and non-participation in sports related to body dysphoria). Crucially, those factors are linked to low bone mineral density and early osteoporosis even in cisgender youth who have never been treated with puberty blockers.
Now let us examine some critically important studies that, curiously, the NYT did not include in this report.
What Went Unexamined: Confounding, Manageable Factors
A review of 20 publications found that trans youth are more likely to have behaviors consistent with eating disorder symptoms or even an eating disorder (ED) diagnosis and may use food restriction or compensatory eating to cope with gender dysphoria. Anorexia nervosa is characterized by low bone turnover and significant bone loss, which are also a risk in bulimia. Mounting evidence notes a 2-4 times greater risk of ED symptoms in trans youth than cis youth, linked to stigma, discrimination, and violence. In one study, 63% of trans youthreported weight manipulation for gender-affirming purposes, to prevent the development of secondary sex characteristics during puberty, or to shape their body to their gender identity. Access to gender-affirming care has been highlighted as essential to decreasing or even resolving eating disorder symptoms for some trans youth, and barriers to this care are associated with exacerbating eating disorder symptoms, psychological distress, and suicidality.
Eating disorders have a more significant effect on bones than puberty blockers ever will. Other confounding factors for low BMD include later age at menarche for AFAB (assigned female at birth) adolescents, lower physical activity, and weight in AMAB (assigned male at birth) adolescents. Other determinants of BMD include genetic-ethnic factors, calcium intake, and weight. Bone health is a critical concern throughout adolescent development—cis or trans—and not mentioning these factors—and causally attributing horrifying outcomes solely to puberty blockers, even when pre-existing risk was explicitly not measured—is blatantly selective framing.
This omission is striking in particular because the authors actually did have access to an expert who could have given valuable advice to parents and practitioners alike. The article cites Dr. Catherine M. Gordon of Boston Children’s Hospital and Baylor, an expert in both affirmative treatment and childhood eating disorders. The article quotes Dr. Gordon as saying, “When they lose bone density, they’re really getting behind,” and then states that Dr. Gordon is “leading a separate study on why the drugs have such an effect.”
This sentence is not entirely accurate. Dr. Gordon is not leading a separate study; she is leading an entire line of federally funded research. Further, she is not investigating why puberty blockers have “such an effect,” as this is easily accessible information that has been available for half a century. Her grant is designed “to open new avenues for identifying preventive strategies to counter potential adverse effects of medical management on bone health in transgender adolescents, and will provide new information on the monitoring of both physical and mental health outcomes.” In other words, Dr. Gordon’s federally funded grant aims to investigate what helps manage potential known risks. In Dr. Gordon’s own words:
My special clinical interests include reproductive endocrinology and bone health. I am actively involved in research in the area of pediatric bone health – in particular, ways to prevent osteoporosis and optimize factors such as nutrition and exercise that are important for bone development. My goal is for all children to enter adulthood with healthy bones. For almost two decades, I have led an independently funded adolescent bone health research group with support from the National Institutes of Health, Department of Defense and private foundations.
The grant abstract that the NYT links specifies that eating disorders cause early bone density loss. Gordon names several factors besides puberty blockers that can contribute to low bone density. Part of that involves, as the NYT states, investigating the full effects of puberty blockers on bone marrow composition, bone density, and skeletal strength. Other initial work associated with the grant involved a study of six trans girls, which noted low bone density in half of the participants before starting puberty blockers. Half of the girls were drastically underweight; one had a low caloric intake and reported little exercise. The authors of the study conclude that screening should include counseling about daily calcium and vitamin D intake, adequate daily calories, and engaging in weight-bearing activity. It is unknown if these bone health risk assessments completed in trans youth before starting puberty blockers will predict the future risk of fractures. While this early study is limited—in part because it only had six participants—it is still actual evidence, unlike anecdotal accounts the NYT spends more words on.
At this point, we must also unpack one quick sentence in the NYT that puts all of this into a more accurate perspective:
Dr. Khosla and Dr. Gordon don’t believe the effects on bones are reason for medical providers to halt use of the drugs in adolescents.
That’s putting it mildly. Dr. Gordon wrote an article advocating for trans youth in Texas and vehemently opposing the State’s efforts to ban gender-affirming care—including puberty blockers. Dr. Gordon explicitly implicates puberty blockers in lowering the high risk for depression and self-harm in trans youth while condemning the involvement of politics in health care. She resigned from her post as pediatrician-in-chief at Texas amid attempts by Texas Gov. Greg Abbott to criminalize gender-affirming care for trans youth. As Dr. Gordon writes:
Understanding the effects of blocking sex steroid secretion on the growing skeleton will provide important information to both pediatric and adult clinicians who care for these patients. Concern about transient bone loss should not discourage this therapy. What is certain is that rates of anxiety, depression, and suicide are strikingly higher among transgender youth, and GnRHa therapy offers hope to these patients. In this patient group, providing a pause in pubertal development offers a life-changing and, for some, a life-saving intervention.
This is a pattern throughout the article: the NYT quotes legitimate medical experts in gender-affirming care but conveniently fails to quote them regarding their positions vis-à-vis the cultural controversy. They directly quote Dr. Stephen Rosenthal when he justifies his stance for not providing blockers as a stand-alone treatment to anyone over 14. However, they merely summarize his stance against attempts to ban puberty blockers—obliquely mentioning that he filed statements in a lawsuit aimed at overturning Alabama’s state-level ban on the medications.
A casual reader could miss that the consensus of anyone with expertise in the subject matter is that blockers should not be banned, but rather that there should be an awareness of potential adverse health effects and that there should be evidence-based risk management practices available for these potential effects. These are important details to unpack because as far as scientists are concerned, the question is not “should children be allowed to access medical transition procedures including puberty blockers?” The questions are, “What is the best possible timing for puberty blockers? What are pre-existing risk factors? How can we manage those risk factors? If we had to give parents of trans youth advice, what would it be?”
The NYT leaves these questions unexamined—and spends its word budget on something else entirely.
Why Did the NYT Even Mention Detransitioners as a Risk of Puberty Blockers?
The third patient the NYT follows across the article is now a young adult detransitioner—a person who initiated one or more stages of transition and later stopped for one reason or another. While detransition, as a phenomenon, is relatively uncommon, it is still a relevant part of discussions about transition and the medical establishment. However, the article is ostensibly about the potential risks of using puberty blockers for long-term health. That risk would be, on paper, equal for both detransitioners and TGD people on gender-affirming hormones, depending on at what point in medical treatment someone detransitioned. The real harm is that the article includes the detransitioner story to construe the possibility of detransition as a risk of puberty blockers.
The NYT discusses the anecdotal account of the detransitioner they interviewed. According to her, she was “fixated on moving ahead with a medical transition” and had doubts shortly after going on testosterone. She claims that she felt “steered” into transition. It is not our place to interrogate her story. What is our place is highlighting that the NYT uses her story to create a false sense of balance and to advance discredited, unevidenced fears about puberty blockers causing iatrogenic gender dysphoria.
Speculative anecdotes like these are inferior in quality to the actual research conducted by the authors of the work the NYT commissioned a review of. While there are legitimate points to be disputed among medical professionals concerning the risks of long-term bone density losses, the NYT also reports:
While many doctors see that as evidence that the right adolescents are getting the drugs, others worry that some young people are being swept into medical interventions too soon.
They do not, however, examine why one side of that is medical consensus and the other is not, or whether any of those worries are supported by evidence more substantial than social media reports or published papers utilizing statements from those social media reports. Indeed, while detransition is—as the NYT highlights—a reason why the U.K.’s NHS has adopted its new policies, its policies are based on questionable—at best!—evidence and have been disputed worldwide by experts.
It is common practice for detransition claims in the media to be backed by anecdotal evidence instead of peer-reviewed research and weaponized by journalists to roll back legal progress. Fears around detransition have been used to delegitimize trans people for over 40 years in order to persuade cis people to believe that trans health care is somehow inherently dangerous and harmful: Look at all these people who regret transitioning! What a giant and irreversible mistake! And yet, transition regret attributed to doubt about gender identity is expressed by 0.09% of people in one study, 0.3% in another, a rate of less than 1% in a third, and 2.4% in a fourth. Overall, medical research on gender-affirming care yields very low rates of regret.
In addition, in a discussion on puberty blockers, adult detransitioner narratives are not relevant. Puberty blockers ostensibly provide a way to consider whether one wants to transition. While anecdotal evidence from the detransitioners the NYT authors talked to suggests that being on blockers made them want gender-affirming hormones more, that’s not inevitable. It’s an idiosyncratic case, by the NYT’s admission—the only reason to labor on detransition as much as the authors do is if they lend credence to the “gender-critical” argument that gender dysphoria is iatrogenic and only persists because of social affirmation and puberty blockers.
Affirmation “Locks In” Transness?
Claims that gender-affirming care, be it social and/or medical, somehow “locks in transness” are espoused by Dr. Kenneth Zucker (known for opposing gender-affirmative care and for questionable treatment practices) and were considered “the most difficult question” by Dr. Hillary Cass, lead on the much-maligned and internationally criticized (and deservedly so) NICE Review: Do those adolescents on blockers so commonly move on to taking gender-affirming hormones because they feel “locked in” to being trans? According to the gender-critical crowd, affirming a youth’s gender identity, whether socially and/or medically with puberty blockers causes a youth to double down on that identity. It’s an oft-cited argument to dissuade parents and school environments from affirming youths’ gender identities when they do not match what was assigned them at birth. It is also an argument for which there is no evidence. It represents the pet theories of those who once claimed that trans identities could be prevented in adulthood by psychotherapy, based on deeply flawed evidence. As Alejandra Caraballo notes:
The main anti-trans talking point for years was that trans kids grow out of it. When that was empirically proven false, they then used it to say that transition was bad b/c it makes them trans.
Yes, many trans youths begin therapy with gender-affirming hormones. Of them, the youth who started on blockers and moved on to gender-affirming hormones do so because they are trans. While a small number of them might decide to detransition‑and the stories of these detransitioners are important!‑that does not mean that their experiences are even remotely the norm.
Building off a fear oft-expressed by the right, the authors note that an estimated 300,000 youth aged 13- 17 in the U.S. “identify” as trans, and the number is increasing. They report an “untold number (of trans people) who are younger.” These authors overlook that prior estimates of trans identification skewed low due to a lack of acceptance, visibility, and support within society, a lack of access to transition-related resources, and attempts to suppress transgender and gender diverse identities. The DSM-5 (released in 2013) made estimates for the prevalence of gender dysphoria that, even at the time, were known to be drastic underestimations. The current numbers are the first to come from actual population studies, and even then, it must be noted that three hundred thousand people only make up 1.4% of 13 to 17-year-olds in the U.S. As such, the statement that “the number is increasing” must be contextualized. Failing to do so is irresponsible, as it leads readers to cast about for causal explanations rather than fairly mundane systemic changes.
A comparison to the antivaccine movement is warranted here. An analogous case study in fearmongering around increasing numbers related to systemic changes was the so-called “autism epidemic.” To antivaxxers, the increasing numbers of autism diagnoses in the 1990s to the 2010s implied an epidemic for which there must be a distinct cause—such as vaccines. The alternative explanation—that increased awareness of autism and more specific, less biased diagnostic criteria simply led to easier, earlier diagnosis of autism—either did not occur to them or was rejected because opportunists sold them “science” with causal explanations. Disgraced ex-doctor Andrew Wakefield, who lost his medical license for ethical violations, fraud, and harm inflicted to children, originated the modern anti-vaccine movement almost single-handedly by claiming a “potential” link between autism and the MMR vaccine. His “research” was published in the respectable medical journal The Lancet, and though it was retracted as fraudulent, the damage was done, and between 1998 and 2006, almost half of the newspapers in the U.S. published “balanced” perspectives. “Balance” meant giving equal coverage to antivaxx and scientific perspectives, which perpetuated the myth of a controversy where none really existed and an illusion of a genuine debate between those two sides within the scientific community. Sound familiar? It should. Mainstream media is often praised for its “balanced” coverage of trans issues; in reality, this coverage sets up the illusion of a true debate between anti-trans ideologues and scientific experts, ignoring the preponderance of evidence for gender-affirming care.
An increase in diagnoses does not necessarily mean a true increase in prevalence. Increasing numbers in autism diagnoses were driven by a change in diagnostic criteria in the 1990s, increased screening and support in schools, and an increase in awareness. It is likely that with autism that we are finally diagnosing somewhere near what the true prevalence rate has always been. The same phenomenon is noted in increasing rates of ADHD, as they likely reflect increased recognition and public awareness of ADHD. The same is also likely to be true for the increasing numbers of trans youth accessing gender-affirming care. Increasing numbers do not represent a crisis or an epidemic, and do not represent evidence in support of a causal, unsubstantiated link. They also do not represent a “real” increase, hack jokes of comedians like Bill Maher, who is also antivaccine, notwithstanding.
Of course, that is hardly the point when fears are invoked around a manufactured “epidemic”: increasing numbers of autism diagnoses are important for the antivaxx movement because they support the utterly unscientific narrative that vaccines cause autism. That the press promoted that narrative in prior decades was irresponsible not just because it laundered Wakefield’s lies to a broad audience—but because what parents actually needed was not fearmongering, but accurate information about autistic children. How do I teach my child to interact with peers who have autism? If my child has autism, what are the best practices for raising them and being mindful of how they think?
Increasing numbers of gender dysphoric youth are important for the gender-critical movement because they support several utterly unscientific narratives (youth are ”pushed” into transitioning; Rapid Onset Gender Dysphoria is a real phenomenon; social support and acceptance encourages trans identification; what we are diagnosing as gender dysphoria is actually mental illness; trans identification is socially contagious; most trans children stop being trans; gender affirmation is dangerous and irreversible) which converge to form the basis of their argument that trans identities need to be questioned, scrutinized, and discouraged, especially in children, because they’re not real and should certainly not be accepted as normal. Much like Wakefield’s fraudulent paper, ROGD is a solution in search of a problem: if one accepts ROGD as factual, it suggests that conversion therapy is a viable solution and that parents don’t need to accept that their trans child is actually trans. They can control whether their child is trans by subjecting them to psychotherapy aimed at making them grow up cisgender—much in the same way the anti-vaccine movement promises parents they can control their child’s development and prevent them from being autistic by refusing vaccines or, if they are autistic, by subjecting them to “autism biomed” quackery designed to “detoxify” them from the supposedly malign effects of vaccines.
Unsurprisingly, conspiracy theories have converged to claim that autistic children are being pushed into “becoming transgender.” Early studies noted increased rates of autism spectrum disorders (ASD) in gender clinics and increased gender diversity in those with autism spectrum disorders. There is a link between ASD and gender dysphoria, but not one of clear correlation and causation. In the gender-critical framework and as supported by Dr. Zucker, autistic trans people are told that their gender dysphoria is a result of their autism, and autism is weaponized against gender-affirming care, with concern trolling similar to that which is presented in the NYT article: save the autistic children from gender ideology; save children’s bones! Yet the historical approach to autism (and being trans) as a problem and a disease undermines this “we’re trying to save our children” argument. Save our children, indeed-as long as they are cisgender and neurotypical.
The authors discuss and quote those in favor of restricting care for these youth, even though relatively few youth can access care in the first place. They show little awareness of how (in)accessible gender-affirming health care is. The authors cite data captured by Reuters, which shows that, for the entire U.S., 4,780 patients with gender dysphoria were put on puberty blockers covered by insurance between 2017 and 2021. This number represents 1.6% of the estimated 300,000 trans youth the NYT presents; these are hardly the hordes of trans youth on blockers that the conservatives warn about. However, the authors suggest that this number “does not capture the many cases in which insurance does not cover the drugs for that use, leaving families to pay out of pocket.”
While there are many cases where insurance does not cover the drugs for that use, we question this statement. How many people, realistically, are paying thousands of dollars out of pocket? The number is likely lower than the number of people for whom puberty blockers are entirely inaccessible, even when medically recommended.
Misleading Claims about the State of the Evidence on Puberty Blockers
The authors illustrate multiple points about puberty blockers and their risks that are not properly contextualized and can therefore mislead readers. One such point is their discussion of using puberty blockers “off-label.” To their credit, the authors note that many drugs are used off-label without FDA approval. They are also correct when they report that a drug approved for one class of patients may not be safe for another. In context, however, these statements are misleading. Trans adolescents have a similar response to puberty blockers as children with central precocious puberty, except for higher estradiol levels in AFAB trans adolescents. (AFAB stands for “assigned female at birth”; AMAB, “assigned male at birth.”) These levels, which are unlikely to be a significant finding, are explained by the fact that trans adolescents most often start blockers at a more advanced stage of puberty. The authors themselves note this discrepancy when assessing bone development risks but do not mention it when discussing the use of blockers as “off-label.”
This is problematic because off-label prescribing is a common practice and not at all experimental. The FDA does not control or limit how health care providers prescribe medications once they are on the market. Puberty blockers have been the gold standard of care treatment for precocious puberty since the 1980s and have been used in trans youth since the late 1980s. In cisgender children, puberty blockers “have an enviable track record of safety and efficacy.” The same medications, formulations, and even doses are used to treat prostate cancer, endometriosis, precocious puberty, and infertility. Yet, in transgender youth, puberty blockers take on the labels “experimental” and “dangerous.” Using puberty blockers to block incongruent puberty in trans youth is not experimental or dangerous, and while there may be risks, the fact that the drugs are prescribed off-label isn’t one of them.
The authors state that the International Endocrine Society “in 2017 had described the limited research on the effects of the drugs on trans youth as “low-quality.”
Pubertal suppression is fully reversible, enabling full pubertal development in the natal gender, after cessation of treatment, if appropriate. The experience of full endogenous puberty is an undesirable condition for the GD/gender-incongruent individual and may seriously interfere with healthy psychological functioning and well-being. Treating GD/gender-incongruent adolescents entering puberty with GnRH analogs has been shown to improve psychological functioning in several domains.
The appeal to dismiss “low quality” research reflects a fundamental lack of understanding about terminology. “Low quality” is a technical term, not a condemnation of the evidence, and does not necessarily imply a particular strength of recommendation. “Low quality” studies often guide clinical practice, especially in cases when there exist few or no RCTs, usually because they cannot be done for ethical and/or practical reasons. If we held all medical interventions to the same quality standards, we would have to outlaw many widely-used medications and deny coverage for some common surgeries. Minimally invasive procedures, such as laparoscopic gallbladder removal, which are grounded primarily in a firm foundation of observational studies, would be deemed “experimental” and challenged. Evidence-based guidelines graded according to the GRADE system, a globally recognized measure of evidence based on the quality of available studies, for gender-affirming puberty blockers for trans youth have been around for years, such as those used by UCSF.
More salient here, any body of scientific literature without RCTs (randomized control trials) will always be considered “low quality” according to the GRADE system, even if the preponderance results of non-RCT studies strongly support a given medical intervention. RCTs of puberty blockers in trans youth are now considered unethical because researchers would knowingly deny standard medical care that addresses gender dysphoria and improves mental health to the control group. RCTs for puberty blockers are also impractical, even if they are not unethical, to the point of being impossible because the subjects in the control group would certainly eventually notice if they started going through puberty while ostensibly on drugs to prevent it. The absence of RCTs-despite the well-documented presence of medical consensus, solid scientific evidence, and rigorous clinical practice guidelines-does not mean there is “no evidence” for gender-affirming treatment.
The ill-conceived and GC-adored NICE review, which condemns gender-affirming medical care for youth as low quality, is linked and referenced in the NYT article and has influenced the NYT critique of puberty blockers. The review was commissioned by Dr. Cass, mentioned earlier, on whose recommendation England’s National Health Service proposed restricting gender-affirming treatment for trans youth to research settings.The review was also thoroughly criticized in the scientific community for, among other things, not understanding what “low quality” actually means in context.
The primary measures used to assess bone density are Z-scores and BMD. Z-scores are comparison measures. A Z-score compares your bone density with the average for a person of the same age and sex (here meant the sex assigned at birth). In other words, if you have a 16-year-old trans girl who was on blockers and then put on estrogen, she’s being compared to a 16-year-old boy going through default puberty. BMD, or bone mineral density, assesses bone quality directly.
Puberty causes an increase in bone density. Puberty blockers cause a decrease in bone turnover. Blocking puberty will then naturally halt the increase in bone density; therefore, bone density will decrease in trans youth compared to cis youth, an expected result that coincides with a reduction in Z-scores. Those on blockers who postpone gender-affirming hormones may be particularly prone to loss of bone mass, as BMD and bone mass are inversely related to the timing of puberty. It is common, and I have written about this before, that studies reporting low bone density in trans youth compare trans youth on blockers to same-aged cis youth in puberty. This is not a fair comparison because puberty is stalled for one group, and bone accrual is halted; puberty and bone accrual are actively happening for the other group. Additionally, those trans youth are most often compared to cis youth who were assigned the same sex at birth, not to cis youth matching their gender identity. The International Society for Clinical Densitometry (ISCD) recommends that the Z-score in trans youth be compared with the average for a person of the same age and the gender conforming with the trans youth’s gender identity. Trans youth treated with puberty blockers in early puberty have changes in bone health comparable to those of cis youth of their experienced gender.
Z-scores and BMD are expected to decrease in trans youth on puberty blockers. We do not yet know how relevant that finding is concerning fractures. After the addition of hormones, Z-scores and BMD increase. While they do not appear to fully “catch up,” at present, it’s worth noting that (as stated above) they were often low to begin with, even before the intervention, due to manageable factors.
NYT’s Evidence, What it Says, and How It’s Covered
Seven studies documenting the association between puberty blockers and bone density in approximately 500 adolescents from Europe and Canada were analyzed for this NYT article. 3/7 studies were also cited in the NICE Review (Klink et al. 2015, Vlot et al. 2017, Joseph et al. 2019.) The studies are all characterized as observational, even though 4/7 are retrospective. The article omits the following findings from the studies analyzed:
Twelve test subjects in Klink et al. 2015 overlap with Vlot et al. 2017; the former study is focused on long-term effects on bone mass and the latter on short-term effects. Klink et al. 2015 note no change in absolute aBMD and BMAD but a decrease in aBMD Z-scores in trans women on puberty blockers; in trans men, absolute aBMD decreased on puberty blockers and increased after addition of gender-affirming hormones. The authors note that postponing gender-affirming hormones beyond age 16 may increase the propensity for loss of bone mass. There is a time component at play in Klink et al. 2015: by age 22, aBMD-Z scores were no longer significantly lower than average for trans men (although the authors note they still trended lower). Vlot et al. 2017 also note that only the BMAD Z-scores of young trans women decreased during puberty blocker treatment, but BMAD remained stable for both male and female cohorts. Vlot et al. 2017 further note that the dosage of estradiol in these studies for trans women was very low–and may have been inadequate for fostering bone density gain. Such doses would not result in anywhere near the levels expected for premenopausal cisgender women, and therefore it is questionable that this limitation is not addressed by the Times.
Joseph et al. 2019 note that it is debatable whether Z-scores remain a valid comparator between youth on blockers and cis youth in puberty, given that GnRHa treatment interrupts the rapidity of bone size increase.
Stoffers et al. 2019, a retrospective study of 62 adolescents included here, even though it is a study on the efficacy and safety of testosterone treatment and not specific to puberty blockers, note a decrease in BMD and z-scores after starting puberty blockers, as expected, with BMD returning to baseline after initiation of testosterone treatment. Z-scores remained lower, but the authors note that they were unclear on whether to use male or female ranges to calculate z-scores. They conclude by recommending vitamin D and calcium supplementation and exercise.
Schagen et al. 2020 report normal BMD and BMAD values for youth before initiating puberty blockers. However, trans girls had z-scores “well below zero.” This aligns with other studies noting less physical activity and more fast-food intake in trans girls. The authors again report the issue with deciding which reference population to use to calculate z-scores and conclude that treatment with puberty blockers causes small decreases in BMAD, z-scores that are normalized by gender-affirming hormone treatment for trans boys, and a pre-existing concern for lower z-scores in trans girls due to lifestyle factors.
Carmichael et al. 2021, an uncontrolled prospective observational study, examined GnRHa treatment as monotherapy in 44 youths and found little change in psychological function and BMD changes consistent with suppression of growth. Subjects on blockers reported more happiness and better peer relationships.
Navabi et al. 2021, a medical records retrospective review of 172 youth with GD seen at one academic children’s hospital, assessed BMD z-scored based on sex assigned at birth instead of gender identity and found no vertebral fractures even in those with significant decreases in z-scores. They also found that most trans youth had vitamin D deficiency at baseline.
As the article’s authors concluded, “The change in bone density while adolescents were on blockers was observed to be zero. The analysis also showed that the adolescents’ Z-scores, a measure of bone density benchmarked to peers, consistently fell during treatment with blockers.”
In other words, there was no change in bone density in 500 adolescents on blockers. Z-scores, expected to decrease on blockers, were indeed observed to decrease. Nothing here is demonstrated that is not common knowledge in the literature. What matters, however, is that many of these studies suggest ways to manage the risk of puberty blockers—the NYT article…doesn’t, even though this information would be beneficial for its readers.
A 2022 narrative review calls for more extensive long-term studies to investigate bone density recovery once puberty blockers are combined with gender-affirming hormone treatment; so far, studies have noted significant increases, with normalized Z-scores for trans boys and Z-scores below zero for trans girls according to lower pre-treatment values. For both populations, the recommendation remains optimizing calcium and vitamin D intake and exercise.
The authors report, “Some doctors and researchers are concerned that puberty blockers may somehow disrupt a formative period of mental growth. With adolescence comes critical thinking, more sophisticated self-reflection and other significant leaps in brain development. Sex hormones have been shown to affect social and problem-solving skills. It’s believed that brain growth is connected to gender identity, but research in these areas is still very new.”
Studies have yet to show any detrimental effect on executive function in youth on blockers, no significant differences in brain development, and significantly better global functioning in trans youth on blockers than in trans youth not on blockers. The study linked to the NYT quote above is a 2020 Consensus Parameterexamining puberty blocker outcomes which noted significant improvement in overall psychosocial functioning and lessened depression in youths treated with puberty blockers.
All of this, taken together, matters because the NYT concludes by asking for “less vitriol, more science” but ignores what the consensus of that science actually is and what future directions that science is directed towards. The consensus is that the benefits of puberty blockers outweigh the risks—the disputes are over how those risks are to be managed and minimized.
The Cost of Misinformation About Trans Youth in Respected Publications
The authors of the NYT editorial chose to interview several health professionals who are not even peripherally involved in the care of trans youth. Dr. Sundeep Khosla, for example, has done many studies on age-related bone loss, osteoporosis, and sex steroid bone changes, but none on trans health care or trans youth and GnRH agonists. He has studied bone health in trans adults, and while he is skeptical that youth on blockers can ever really catch up in bone mineral density, the “price” he warns of is one that he views as outweighed by the benefits of gender-affirming treatment.
Yet he, and actual experts, such as Dr. Gordon, are quoted here alongside Dr. Matthew Benson, a pediatrician with no expertise in trans medicine. Another professional featured here is Dr. Kaltiala, a researcher who was instrumental in restricting trans health care in Finland and who argued in favor of restrictions in Florida. She’s been interviewed by Stella O’Malley and Sasha Ayad and repeated the discredited claim that 80-85% of trans adolescents desist at the Florida Boards of Medicine Joint Meeting. She (ideologically) believes puberty blockers and hormone therapy should not be available to anyone under 18.
Simply put, given these choices and their coverage of available evidence, it strains credulity that the NYT was aiming for any balanced effort when its editors commissioned this article. Indeed, several of their sources have arguably directly harmed the trans community. Further, the authors didn’t bother speaking with the trans community—several of whom are scientists and doctors who have written on these matters. The cost of ignoring trans health care experts is felt here, though it is not hard to see why they would not want to be interviewed for the New York NYT.
Indeed, let us emphasize again how this article is reminiscent of how antivaxxers launch disinformation campaigns that suppress actual scientific debate. Dr. Gorski once coined the term, the “central conspiracy theory of the antivaccine movement” to describe the theme that underlies nearly every antivaxx theory: “they knew, but covered it up,” e.g., the CDC “knew” that vaccines cause autism but covered it up with manipulated data. Antivaxxers malign the potential “long-term effects” of vaccines in children, claiming they are unknown and unproven; GC ideologues repeat the same sentiments with puberty blocker use in trans adolescents. Antivaxxers and GC ideologues alike appeal to the autonomy of parents and guardians to make decisions about health care for their children. Both teams regularly publish poorly designed studies and editorials intended to stoke fear. Both believe their ideology and politics match the rigors of science and that, as such, there is a fair and balanced “debate” between them and actual medical experts. Both teams see any attempt to counter their views as an impingement on their free speech and as “silencing.” No wonder there has been such a convergence between antivaxxers and GC ideologues and…other groups. In fact, it has been argued that the complicity of well-regarded news media in uncritically parroting the claim that vaccines cause autism was instrumental in mainstreaming anti-vaccine conspiracy theories, the consequences of which haunt the world to this day.
No wonder antivax conspiracy theorists like Mike Adams love the NYT article and cite it approvingly.
The NYT authors state, “For some medical professionals across the country, there are too many uncertainties about the effects of blockers to provide the treatment. Among them are seven pediatric endocrinologists and pediatric endocrine nurse practitioners in Florida who recently wrote to the state health department that evidence to support the use of those treatments in adolescents “is simply lacking” and asking that it be confined to research settings.” It is disturbing, again, to see, in a relatively short article, another mention of confining gender-affirming care for trans adolescents to research settings; worse, the NYT neglects to mention that 300 Florida health care professionals also sent a letter, letting the state know that they got it wrong. And that the Endocrine Society opposes the Florida Board of Medicine ban.
>Denying access to puberty blockers for trans and gender-diverse youth is not a neutral option; puberty doesn’t wait and can exacerbate suicidality, self-harm, and suffering in dysphoric youth. The evidence shows that the benefits of gender-affirming treatment with puberty blockers-lower depression rates and suicidality, improved quality of life and global functioning- significantly outweigh any risks, such as decreases in Z-scores with bone mineral densities that largely remain stable on puberty blockers. The authors have nothing to point to but anecdotes to the contrary, as they admit: “While there is no systematic record-keeping of such cases, some anecdotal evidence is available.”
Even the ominous note they end on, a “soon-to-be-published study” showing that the longer a youth stays on blockers the lower their bone density, isn’t the harbinger they think it is, because, first: yes, of course, that’s what we have all been saying happens, and, second: the author of the study, Dr. Nokoff, does not want her scientific research misconstrued for political gain, and, third: the cross-sectional study is still in abstract formonline, and it is impossible to draw meaning from the results.
Research studies continue to confirm that puberty blockers are safe, effective, and have minimal complications. It is disingenuous of the NYT to claim otherwise. It is even more harmful for the NYT not to report on steps people can take to manage the risks of puberty blockers, especially when the literature they reviewed highlights some of these steps. This irresponsible journalistic attempt only fuels today’s atmosphere in which there are growing efforts to ban gender-affirming care for TGD youth based on ideology rather than clinical science.