Puberty blockers: what are they and what are the concerns about?

Children with gender dysphoria will no longer be routinely given puberty suppressing hormones, also known as puberty blockers. a review from NHS England concluded that there was insufficient evidence for its safety and effectiveness.

Under the new policy, the hormones will only be available to children with gender dysphoria through clinical trials designed to fill gaps in medical knowledge, although accommodations are expected to be made on a case-by-case basis in exceptional circumstances. The treatment of young people who are already receiving the hormones will not be affected.

Therapies to suppress puberty emerged from work in the 1960s and 1970s, when researchers discovered what was ‘the conductor of the reproductive system”. In work that involved the dissection of hundreds of thousands From pig and lamb brains, Andrew Schally and Roger Guillemin extracted and determined the structure of gonadotropin-releasing hormone, or GnRH, work that won them the 1977 Nobel Prize in Medicine.

GnRH is produced in the hypothalamus of the brain. When released, it causes the pituitary gland to secrete even more substances, namely follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which stimulate puberty and sexual development. In men, hormones tell the testicles to make testosterone. In women, they cause the ovaries to produce estrogen and progesterone.

What researchers found remarkable as they began to understand GnRH was that while pulses of the hormone stimulate the pituitary gland to produce other puberty-stimulating hormones, a continuous dose effectively shuts down production of FSH and LH, putting puberty on ice.

Today, synthetic analogues of GnRH such as triptorelin are given for prostate cancer and endometriosis, and they are also approved for children with precocious puberty, a condition that affects more girls than boys. Affected girls may enter puberty as toddlers, but hormone therapy slows it down. When children stop taking drugs, they go through puberty normally. “It has had a lot of benefits in these children,” says Ashley Grossman, professor of endocrinology at the University of Oxford.

Studies in children given puberty-suppressing hormones for precocious puberty suggest that the therapy is generally safe, but questions remain. Some researchers note that there is little data on important outcomes, such as: cognitive development, fertility and the risk of cancer and metabolic diseases make it difficult to draw firm conclusions about their long-term impact.

Less is known about the use of puberty suppressing hormones in children with gender dysphoria. The drugs have been used off-label — when a drug is prescribed for a use other than the one listed on the label — for the condition since the mid-1990s, to buy time for patients to explore their gender identity and to combat potentially distressing situations. sexual maturation.

But Few large, robust studies have examined the consequences. “It’s a different situation when a child is about to enter puberty and you turn the whole thing off, and that’s really what we don’t know about the long term,” Grossman says.

Some research shows that puberty suppression can improve mental health And welfare in young people suffering from extreme problems with gender dysphoria, but many findings are based on small numbers of patients. Research in this area is often disputed. Making headlines found from Massachusetts General Hospital in 2020 suicidal thoughts were less common in transgender adults who had been prescribed puberty-suppressing hormones during adolescence, compared with those who wanted them but went without. But critics said the survey used was unreliable. One claimed that the study “contributed nothing”.

Puberty is a crucial time for bone and brain development. Multiple studies suggest that puberty blockers affect bone density and possibly make bones weaker, but here too the picture is not entirely clear. Jennifer Osipoff, a pediatric endocrinologist at Stony Brook University in New York, prescribes puberty blockers for gender dysphoria. To limit any risk to bone health, she supplements patients with calcium and vitamin D.

The possible impact of puberty suppression on the maturing brain has received little attention from researchers. One study flagged drops in IQ during hormone treatment for precocious puberty, but no one has systematically studied this possible cognitive effects of the cessation of puberty in adolescence and whether any changes are reversible.

For some researchers, these longer-term results need to be well understood before prescribing therapy. “No area of ​​medicine can operate ethically in such a knowledge vacuum,” says Sallie Baxendale, professor of clinical neuropsychology at University College London. She also has “serious concerns” about the ability of adolescents to provide truly informed consent to drugs that “interrupt the construction of the neural architecture that underlies complex decision-making.”

Osipoff agrees that there is “not a lot of scientific research,” but based on her patients and reports from other clinics, she strongly believes the benefits outweigh the risks. The hormones can not only ease the discomfort of gender dysphoria, she says, but can also reduce the need for surgery later, for example if a trans man wants to have breast tissue removed. “When I see how severe the mental health issues are in so many of my patients, and I say I can do something to help eliminate some of that suffering and not offer it, that just seems inhumane,” she says .