Is Suppressing Puberty the Right Course When a Child Questions Their Gender?
Suppressing puberty in a child who's questioning their gender identity might seem extreme, but the therapy is relatively safe and could significantly lower their risk of suicide, a new study reports.
Adolescents who wanted and received puberty suppression were 60% less likely to have considered suicide within the past year and 30% less likely to consider suicide throughout life, according to findings published in the February issue of Pediatrics.
Balancing potential risks
"This study is the first to show that access to pubertal suppression for transgender youth is associated with lower odds of suicidality," said lead researcher Dr. Jack Turban, a resident psychiatrist at Massachusetts General Hospital in Boston and McLean Hospital in Belmont, Mass.
Puberty suppression is reversible, relying on medications that tell the brain to stop releasing the gender-related hormones that set off sexual maturity, he said.
"This allows transgender youth more time to decide what they want to do next in terms of their gender affirmation," Turban said. "If they ultimately decide they want to undergo their endogenous puberty, the medication can be stopped and puberty resumes itself."
The most notable long-term health risks associated with puberty suppression are impaired future fertility and low bone density that could slightly increase risk of broken bones, said Dr. John Lantos, senior author of an ethics analysis that accompanies the suicide risk study.
"Figuring out the best approach to a child or a teenager with gender dysphoria is difficult, because it requires balancing the risks of medical treatment with the psychological benefits that go with gender-affirming therapy," said Lantos, director of pediatric bioethics at Children's Mercy Hospital in Kansas City, Mo. "In many cases, we don't have good long-term outcome data on either the risks or the benefits. We're trying to make our best guesses."
As many as four out of 10 transgender adults have attempted suicide, researchers said in background notes.
Questioning starts early
While children might question their gender identity at a young age, their anguish tends to increase as they near puberty, Lantos said.
"Once puberty starts, the stakes are raised because puberty unleashes all these bodily changes that people don't want and are psychologically distressing," he said.
Turban's team surveyed more than 20,600 transgender adults, aged 18 to 36, asking questions about their use of puberty suppression and their mental health.
About 17% said they had wanted puberty suppression, but only 2.5% received hormone-blockers, the researchers found.
Those who received the treatment had a significantly lower risk of suicidal thoughts, after adjusting for other variables including the level of family support they received, the survey found.
"Many transgender youth have intense dysphoria as their bodies start to develop in a way that does not match who they know themselves to be," Turban said. "Pubertal suppression pauses those changes to allow youth more time to decide what to do next."
One child's personal story
In their accompanying analysis, Lantos and his colleagues discuss the case of a 15-year-old who was born male but has displayed gender-diverse behaviors since preschool.
"Children often have a clear sense of their gender identity as young as 3 or 4 years old," said senior study author Dr. Alex Keuroghlian, director of the Massachusetts General Hospital Psychiatry Gender Identity Program. "However, no medical intervention occurs for younger children, and the best practice is to provide psychological and social affirmation until very early puberty."
The child, called "EF" in the paper, presented as male at school but identified and dressed as a girl at home. But neither felt quite right, the researchers said. EF began to identify as agender -- neither boy nor girl. EF preferred being referred to by gender-neutral pronouns "they" and "them."
The onset of puberty at 11 increased EF's anxiety, as they became concerned about their voice deepening and body hair appearing. The preteen started puberty-suppression treatment at age 12.
"What made this case more complex than that typical case is that after several years, doctors said OK, we've delayed puberty for long enough now, which gender do you want to be?" Lantos said. "The patient said neither. I'm perfectly happy like this. Keep me on puberty-blocking drugs."
EF's bone density has fallen to very low levels compared to other people, and it can be expected to continue falling, the researchers noted. Gender-based hormones like testosterone and estrogen play an important role in maintaining bone health.
But while EF is at increased risk of fractures, that risk needs to be put into perspective, the researchers said. A 50-year-old man with bone density similar to EF's has a 0.2% to 0.3% risk of hip fracture and a 1% to 2% risk of other fractures within the next decade.
Dr. Joshua Safer, executive director of the Mount Sinai Center for Transgender Medicine and Surgery in New York City, explained that "the greatest known risk for puberty suppressants is the risk to bone development. That said, the osteoporosis risk is so small that it has been hard to demonstrate."
Time to reflect on identity
Safer said he would be "very relaxed" about using puberty blockers in a child who might be transgender, arguing that the medications are a conservative treatment that give kids time to reflect on their identity.
"They have been used in numerous circumstances and appear to be exceedingly safe at least for a couple of years," he said. "They are easy to discontinue. In the majority of cases, the children using them are transgender after all and use of puberty blockers can mean less surgery later for these children, which is a huge benefit."
Lantos said parents with a child questioning their gender identity should take the matter seriously and not minimize it. They should discuss it as a family with their doctor, and seek a referral to a center with expertise in gender issues.
"Most children's hospitals now have gender identity clinics, so as long as people can get to a children's hospital they usually can find people with this expertise," he said.
Keuroghlian added that strong family support is a key factor in transgender youths' mental health.
"Parents of transgender kids ought to connect with local services and programs dedicated to helping families learn to support their child's gender affirmation at home, at school, and in their community," he said.
The American Psychiatric Association has more about gender dysphoria.
SOURCES: Jack Turban, M.D., M.H.S., resident psychiatrist, Massachusetts General Hospital, Boston, and McLean Hospital (Harvard Medical School), Belmont, Mass.; John Lantos, M.D., director of pediatric bioethics, Children's Mercy Kansas City, Kansas City, Mo.; Alex Keuroghlian, M.D., M.P.H., director, Massachusetts General Hospital Psychiatry Gender Identity Program, Boston, and director, National LGBT Health Education Center, Boston; Joshua Safer, M.D., executive director, Mount Sinai Health Center for Transgender Medicine and Surgery, New York City, and professor of medicine, Icahn School of Medicine at Mount Sinai, New York City; February 2020, Pediatrics