Why gender-questioning youth continue or discontinue puberty blockers

Zinnia JonesPuberty-blocking medications for trans or gender-questioning adolescents, which reversibly halt the production of sex hormones and prevent the development of undesired secondary sex characteristics for as long as the medication is continued, have long been the subject of unnecessary controversy and poorly-supported criticism. Those who oppose this gender-affirming medical care for adolescents have frequently claimed that the use of puberty blockers actually causes otherwise-cisgender youth to “become” transgender when they would have remained cisgender in the absence of this treatment (in reality, puberty blockers are widely used in cisgender youth with precocious puberty and do not appear to “cause” transness). Others have alleged that all trans or gender-questioning adolescents who use puberty blockers will go on to choose to transition via cross-sex hormone therapy and further medical treatment, and that this therefore proves puberty blockers must have caused them to continue being trans; as it turns out, a small proportion of gender-questioning youth on puberty blockers do go on to discontinue treatment and identify as cisgender, and the high percentage who continue transition is far more plausibly attributable to transness causing use of puberty blockers rather than use of puberty blockers causing transness.

A recent study of the outcomes of 143 trans and gender-questioning adolescents treated with puberty blockers at the Curium-Leiden University Medical Center gender clinic in the Netherlands provides further detail on how many of these youth go on to transition, how many elect against transitioning, and what motivates these key decisions.

Brik et al. (2020) studied 38 trans girls and 105 trans boys who had received puberty blockers at some time during November 2010 to January 2018. Trans girls started taking puberty blockers at a median age of 15 years, with trans boys starting at a median age of 16.1 years, although their ages ranged from 10.1 to 18.6 years; puberty blockers are generally recommended to be given at Tanner stage 2, the initial stage of natal puberty. Of those who went on to start cross-sex hormone therapy, trans girls started HRT after a median of 1 year on puberty blockers, while trans boys began HRT after a median of 0.8 years. 87% of those who received treatment with puberty blockers went on to start HRT; the group of those who did not includes both those who chose to discontinue transition entirely, and those who continued to be on puberty blockers for a longer duration for other reasons.

Among youth who had been taking only puberty blockers without hormone therapy for one year or longer, in only one case was this due to “more time needed for decision about gender-affirming hormone treatment by the adolescent”, and in one other this was needed “for further diagnostics by the gender team … because of non-binary aspects”. Conversely, in six cases this was noted to be due to “family issues such as lack of parental support and/or acceptance of gender dysphoria or social problems such as lack of a safe home”, and in eight cases this was simply due to logistical issues such as missed or rescheduled appointments.

The authors also examined the specific reasons motivating the nine adolescents, 6% of those studied in total, who chose to discontinue treatment with puberty blockers. Notably, of these, only one was assigned male at birth, while eight were assigned female. However, this group did not uniformly report a straightforward cause such as discovering that they were cisgender after all. Three, all trans boys, had discontinued puberty blockers but then went on to receive testosterone; a fourth trans boy switched to taking lynestrenol to suppress menstruation but wasn’t old enough to start testosterone.

Out of the nine who discontinued treatment, five – 3.5% of the subjects overall – did not want further transition treatment. Their reasons for this decision were diverse: One AFAB reportedly felt that “she might want to live as a woman without breasts” and still “dreaded breast development and menstruation”; another AFAB stated that this decision was made by the gender clinic and that they still feel “like a man”:

The decision to stop GnRHa to my mind was made by the gender team, because they did not think gender dysphoria was the right diagnosis. I do still feel like a man, but for me it is okay to be just me instead of a he or a she, so for now I do not want any further treatment.

A third AFAB reported that they now identified as neither a man nor a woman; one AMAB continued questioning his gender identity after falling in love with a woman and stated he was now happy to live as a man; and a fourth AFAB stated: “I could feel who I was without the female hormones. . . . It was an inner feeling that said I am a woman.”

To sum up:

  • It is not the case that 100% of trans or gender-questioning youth who use puberty blockers go on to receive cross-sex hormone therapy; this study, much like several previous studies, found that a small number do discontinue puberty blockers and do not go on to transition.
  • Delays in continuing on to hormone therapy were rarely due to genuine uncertainty regarding the presence or absence of gender dysphoria; this was more often due to external issues such as unsupportive family, unstable living situations, or delays in appointments.
  • Those who did not go on to transition were not universally motivated by uncomplicated regret, misdiagnosis, or cisgender identity. Instead, several of these individuals reported persisting gender-dysphoric symptoms or nonbinary identity.
  • Among those who later went on to identify with their assigned sex, the use of puberty blockers did not obstruct or prevent this exploration of their gender – they were able to discover that they were (presumably) cisgender after all even when taking puberty blockers.

As the authors note, because this study was observational rather than experimental, it “does not allow conclusions about any possible effect of GnRHa treatment on gender identity development.” They also explain why an experimental study design would be impractical if not impossible, as previously discussed:

However, many would consider a trial where the control group is withheld treatment unethical, as the treatment has been used since the nineties and outcome studies although limited have been positive (de Vries et al., 2014; Smith, van Goozen, & Cohen-Kettenis, 2001). In addition, it is likely that adolescents will not want to participate in such a trial if this means they will not receive treatment that is available at other centers. Mul et al. (2001) experienced this problem and were unable to include a control group in their study on GnRHa treatment in adopted girls with early puberty because all that were randomized to the control group refused further participation.

For the vast majority of trans and gender-questioning adolescents who begin taking puberty blockers, this treatment is appropriate for them and an initial step in medical transition before continuing on to hormone therapy. Discontinuation without transitioning is very uncommon, and even among those who decide against transitioning, the reasons for doing so are complex and not usefully captured by an assumption of misdiagnosis or regret. For those who don’t go on to transition, the reversible pause of puberty blockers offers exactly what it’s intended to: room to explore, develop, and discover oneself before making a more permanent decision.

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About Zinnia Jones

My work focuses on insights to be found across transgender sociology, public health, psychiatry, history of medicine, cognitive science, the social processes of science, transgender feminism, and human rights, taking an analytic approach that intersects these many perspectives and is guided by the lived experiences of transgender people. I live in Orlando with my family, and work mainly in technical writing.
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