I avoided talking about childhood medical transition in the original manuscript of Autoheterosexual: Attracted to Being the Other Sex. I avoided it because I figured my book was already potentially controversial enough and did not want to add more fuel for the eventual flames. I decided that this hesitance was insufficiently courageous, however, so I added this chapter about juvenile transsexualism.
The more I read, the more I became alarmed by not only the global yet poorly understood effects of GnRH analogues, but also how much clinicians were flying blind in transitioning children. After all, there are two distinct etiologies of gender dysphoria and clinicians still don’t take this absolutely foundational information into account. Their avoidance of reality is embarrassing; I will not be surprised when the lawsuits roll in and it all comes crashing down.
If I were to write about this subject again, I would spend more time dissecting the risks and benefits based on both sex and etiology. Male sexuality is comparatively rigid, and masculinization is particularly rapid and irreversible. Puberty blockers seem more dangerous for females and also less necessary to help them achieve a cross-sex aesthetic. Between the two sexes and two etiologies, I suspect that autogynephilic males are the most likely to benefit and least likely to regret youth medical transition—after all, they are the biggest cheerleaders of this practice.
With that said, the way that autogynephilic transsexuals tried to institutionalize juvenile transsexualism showed an appalling disregard for potential harm to the other three groups of gender-dysphorics: homosexual males, homosexual females, and autoandrophilic females. This disregard was likely inevitable because acknowledging discrete transgender etiologies is anathema to most autogynephilic transsexuals. However, it showed once again that inmates should not run the asylum.
If juvenile transsexualism is to continue, it’s time for evidence-based clinicians to wrest control of this practice from ideologues. Every single instance of youth gender transition should be extensively recorded in a standardized way, collected in a centralized database, and made widely available to researchers. Arriving at reliable knowledge through the scientific process is the most reliable way to enhance human flourishing, and juvenile transsexualism is no exception to this broader pattern. It’s time to let the scientists do their jobs.
As transgenderism has become more widely understood and destigmatized, the number of children and adolescents seeking treatment at gender clinics has surged. To meet the needs of this rapidly growing population, gender clinics are proliferating.
Some of these clinics give kids drugs that strip their bodies of hormones to forestall their default puberty. People in favor of this approach argue that suppressing puberty will give the children and their clinicians more time to decide whether medical transition is right for them. In reality, however, almost all children who start taking puberty blockers for their gender issues will continue onto cross-sex hormones at a later date.
In the matter of juvenile transsexualism, there is a genuine conflict between conventional ethical considerations and the realities of human biology. Puberty happens before kids are mature enough to truly grasp the implications of their decision to transition. Some of these child transitioners will consider medical transition to be the best decision they ever made, but others will deeply regret it.
It’s impossible to know for sure whether a would-be transsexual child will derive overall benefit or harm from medical transition[i]. The long-term outcomes of medical transition in minors are still unknown, and studies in this realm tend to be of low quality[ii].
The practice of medically transitioning youth has spread rapidly. It’s also heavily politicized. Driven by the urge to do good, inexperienced clinicians will help some kids have a good life—and lead others to ruin.
When all is said and done, there will be stories of medical malpractice wherein clinicians gave kids puberty blockers, hormones, and surgeries despite obvious warning signs that such treatment was inadvisable. There will also be stories from grateful transsexuals who overflow with gratitude for the doctors who took a chance on them.
It’s truly a mixed bag.
It’s also unknown whether doctors currently facilitate medical gender transition in youth in a way that leads to net benefits instead of net harm. If, hypothetically, child transition as currently practiced is harmful overall, is it possible to instead do it in a way that leads to overall benefits? And if so, what exactly would that set of clinical guidelines, methods, and medical interventions look like?
It worries me that kids are going through medical transition well before they would otherwise be able to give consent for such serious medical interventions. Worse yet, there is not yet a solid body of high-quality evidence demonstrating the efficacy of juvenile transsexualism. Youth gender transition is still quite new and experimental, and its long-term outcomes unknown[iii].
There are two aspects of juvenile transsexualism, however, that I feel confident enough about to say something here. One is the need to curtail the use of puberty blocker monotherapy because being hormonally sexless wreaks havoc on the human body. The other is the need to expand the scope of data collection to improve trans healthcare outcomes for future generations.
I’ll start by elaborating on the need for more robust data collection in transgender healthcare.
Collect More Data, and Follow Up for Longer
Trans people would benefit in the long term if clinicians coordinated their efforts to achieve large-scale, systematic collection of data from gender-dysphoric people of all ages. The best way to learn from the mistakes and successes happening now is to measure them.
For decades, Dutch and Canadian gender clinics administered questionnaires to gender-dysphoric people and stored their responses in databases. This data formed the basis for dozens of studies, including Blanchard’s famous studies that empirically demonstrated the validity of the two-type MTF model.
Other clinicians operating today should follow this example. By forming cooperative networks such as the European Network for the Investigation of Gender Incongruence (ENIGI)[iv], clinicians can gather data on a larger scale and thus enable deeper investigation.
With more data, clinicians could better predict whether someone is a good candidate for gender transition. By publishing better studies, researchers could help the transgender health community improve treatment outcomes.
Technological advances can facilitate these changes. Electronic medical records can follow patients better than the paper records of the past, so it’s more possible than ever to obtain long-term data on outcomes. If medical organizations coordinated their actions to collect data from trans people throughout their lives, it would improve transgender health care.
As it stands now, too many transgenderism studies record a snapshot of time, and too few examine outcomes over a long period of time. Making a systematic, long-term effort to gather longitudinal data can help correct this shortcoming in the transgender literature.
Transsexualism is a long-term decision. Its study requires long-term follow-through.
Hormones, Blockers, and Mitochondria
Over the next several pages, I’ll show that sex hormones are essential for maintaining physical health, and that while using drugs to strip the body of sex hormones is likely to harm humans of any age, it’s especially bad for pubescent youth.
I’ll also show that social transition and puberty blockers each greatly increase the odds of kids staying on the transsexual path—these interventions cannot be considered neutral.
To understand why puberty blockers can wreak havoc on human health, it’s important to understand some basics about how hormones work, as well as how they act upon mitochondria and thus impact cells throughout the human body.
Sex Hormones Impact All Bodily Systems
Sex hormones affect the creation, maintenance, and function of our tissues and organs by binding to receptor sites. The impact of sex hormones is systemic and not limited to reproductive or sexual functioning.
Sex hormone receptors are found throughout the tissues and organs of the human body. This means they play a regulatory role throughout the body and directly or indirectly impact all of its processes.
Scientists have found receptor sites for sex hormones in the brain[v], heart[vi], gastrointestinal system[vii], immune system[viii], liver[ix], eyes[x], vocal folds[xi], fat cells[xii], skin[xiii], muscles[xiv], joints[xv], bones[xvi], and more. These receptor sites are everywhere.
Hormones are especially influential in determining the strength of bones. For females and males alike, a shortage of sex hormones leads to loss of bone mass and strength[xvii].
Sex hormone receptor sites are also found in mitochondria[xviii], the organelles inside our cells that produce adenosine triphosphate (ATP), the form of chemical energy that cells require to function. Due to their essential role in energy production, mitochondria exist in cells throughout the human body, which means hormones influence a wide variety of tissues by changing how mitochondria function.
Mitochondria
When the mitochondria within a cell produce insufficient energy for the cell to keep living, that cell will die. Proper mitochondrial function is essential.
If our mitochondria stop, we stop. (This is the mechanism by which cyanide kills).
As mitochondria produce their chemical energy, they sometimes create reactive oxygen-based molecules known as reactive oxygen species, which damage DNA, proteins, and other molecules in the body. This damage is oxidative stress, and the chemicals that help combat this damage are antioxidants.
Although it’s normal for mitochondria to produce some oxidative stress, when enough of this damage accumulates, it can lead to mitochondrial dysfunction, a state in which mitochondria deteriorate in form and function, becoming less efficient at producing energy and releasing even more reactive oxygen species.
When mitochondria aren’t functioning properly, disease states are likely to follow—especially in energetically expensive organs like the brain and heart. In an influential paper that’s been cited over six thousand times, the authors concluded that “mitochondrial dysfunction and oxidative stress occur early in all major neurodegenerative diseases, and there is strong evidence that this dysfunction has a causal role in disease pathogenesis”[xix].
Unsurprisingly, mounting evidence suggests that mitochondrial dysfunction plays a role in the development of depression and bipolar disorder[xx]. Mitochondrial dysfunction is implicated in heart disease, too[xxi].
Mitochondrial dysfunction is one of the hallmarks of the aging process[xxii], and the accumulation of oxidative damage is thought to be one of the primary causes of the aging process[xxiii].
Estradiol Protects against Mitochondrial Dysfunction
Estradiol, a form of estrogen and the primary female sex hormone, acts both directly and indirectly upon mitochondria to change how they function[xxiv]. Estradiol has a protective, antioxidant effect on mitochondria in the brain[xxv]. It helps protect cells by improving mitochondrial efficiency and reducing the production of reactive oxygen species[xxvi].
These effects are so pronounced that it leads to measurable differences in mental performance. Experiments on estrogen-deprived rhesus monkeys found they performed worse on a test of working memory than those who received estrogen therapy, and the mitochondria in the corresponding part of their brain were also more likely to be misshapen—a sign of oxidative stress[xxvii]. This finding demonstrated that the health of mitochondria directly relates to mental performance outcomes[xxviii].
Authors of a study examining the brain mitochondria of rats whose ovaries had been removed came to a similar conclusion. A single dose of estrogen significantly improved mitochondrial function, a change the authors described as “a systematic enhancement of brain mitochondrial efficiency”[xxix].
Gonadotropin-Releasing Hormone (GnRH) and Sex Hormones
The pituitary gland secretes hormones called luteinizing hormone (LH) and follicle-stimulating hormone (FSH), both of which interact with tissues in the gonads to drive the production of estrogens and androgens. Since LH and FSH stimulate activity in the gonads, these hormones are known as gonadotropins.
Accordingly, the hormone that signals their release is called gonadotropin-releasing hormone (GnRH).
When working properly, these various hormones signal to each other in ways that keep physiological systems in balance. The release of GnRH leads to the release of LH and FSH, and these induce the release of estrogens and androgens which then provide attenuating feedback moderating the later release of GnRH.
During childhood, GnRH levels are low. But as GnRH activity ramps up during the onset of puberty, so does the production of sex hormones. It’s at this time that some gender-dysphoric kids want to get on GnRH agonists (aka puberty blockers).
GnRH agonists work by binding to GnRH receptors. But unlike the natural functioning of GnRH, which occurs in pulses, GnRH agonists constantly activate GnRH receptors. The body then responds to this overstimulation by reducing the number of GnRH receptors.
With far fewer GnRH receptors around, the release of LH and FSH drops dramatically. In this state, the body produces almost no estrogens or androgens. People who take GnRH agonists without supplementing with sex hormones will exist in a sexless hormonal state that leaves their body without the protective, regulating effects of estradiol and other sex hormones.
In a sexless hormonal state, tissues and organs with sex hormone receptors won’t receive the important hormonal signals that help keep them in good working order. Hormone levels are especially relevant when it comes to bone health—both males and females lose bone mass and bone strength when they have a shortage of sex hormones[xxx].
This effect is even more relevant during puberty. Bone mass typically doubles over the course of puberty and reaches its peak density near the end of adolescence[xxxi]. If people don’t have adequate hormone levels during puberty, however, their bones won’t grow as strong. This leaves them at greater risk of osteoporosis and other bone ailments.
GnRH Agonists Have Hella Side Effects
Doctors prescribe GnRH agonists such as leuprorelin and triptorelin to children in order to delay puberty—either because they are on the transsexual path, or because their puberty came too early. Females hit puberty earlier than males, so they receive puberty blockers for precocious puberty more often.
Doctors give GnRH analogues to adult males for testosterone suppression during prostate cancer treatment. Doctors also give GnRH agonists to adult females for the purpose of reducing gynecological issues such as endometriosis or uterine fibroid tumors.
More studies have been conducted on the effects of GnRH agonists in females, so I’ll primarily draw upon that research. It’s worth noting, however, that research on males who receive GnRH agonists as part of prostate cancer treatment shows they lose more bone mass and have more bone fractures than males who aren’t testosterone-deprived[xxxii].
Among females, side effects from GnRH agonists seem not only more common but also more widespread within their body systems. Overall, these side effects support the idea that estradiol-deprivation-induced mitochondrial dysfunction plays a key role in their genesis.
Despite widespread side effects in females, doctors still prescribe GnRH agonists such as leuprorelin for the treatment of endometriosis and uterine fibroid tumors.
In one study that followed 3,153 adult females taking prescribed leuprorelin, an astounding 77% of them reported joint pain[xxxiii]. In addition, about 36% reported increased propensity toward negative emotions, 43% reported memory loss, and 48% reported irritability[xxxiv]—all of which suggested that leuprorelin had negative impacts on their neurological functioning.
Adult females who have taken GnRH agonists commonly report overt neurological issues like headaches and migraines, or energy-related issues like sleepiness, fatigue, and insomnia[xxxv]. Psychiatric symptoms like depression, anxiety, and susceptibility to changing moods are common, as are connective tissue-related symptoms like joint pain, muscle pain, and cracked teeth.
These negative effects on memory and mood are typical. Other studies that directly tested the working memory of adult females on leuprorelin treatment have found that it’s associated with memory deficiencies and declines in mental health[xxxvi].
Females who halt their precocious puberty with GnRH agonists show a decline in general intelligence over the treatment period[xxxvii]. As adults, many report long-term neuronal and bone-related health issues[xxxviii]. Psychiatric symptoms are common, too.
Altogether, these side effects point to the central role that hormones play in maintaining proper mitochondrial function[xxxix] as well as the health of bones and other connective tissues[xl].
Puberty Blocker Monotherapy Weakens Bones in Transsexual Minors
Under the influence of sex hormones, bones strengthen significantly during puberty. But kids on puberty blockers lack these hormones, so their bone strengthening slows or halts, leaving them behind their pubescent peers.
Several studies have found that even prior to taking puberty blockers, MTFs lag behind other males in terms of bone mineral density[xli], and FTMs who start blockers in early puberty lag behind other females in terms of overall bone mineral density[xlii].
When they go on blockers without cross-sex hormones, biochemical markers of bone growth drop in both FTMs and MTFs, signaling that bone growth has stalled[xliii].Their bone mineral density, a key measure of strength, also drops[xliv]. In this sexless hormonal state, their waist-to-hip ratio demasculinizes, their lean body mass drops, and their body fat percentage increases[xlv].
Once cross-sex hormones are added, though, they start shifting toward other-sex norms for all these characteristics[xlvi]. Their bones begin strengthening, too. After two to three years of receiving cross-sex hormones, bone mineral density in FTMs approaches or reaches norms for their sex, but MTFs still lag behind[xlvii]. A study that measured bone stats even later in life, at age twenty-two, found a similar pattern[xlviii].
When interpreting these findings, it’s important to consider that males tend to have more bone than females[xlix]. Much, but not all, of this difference is because males are bigger. Even when accounting for size differences between sexes, however, males still have more bone[l].
With this sex-based difference in mind, it makes sense that trans men showed less bone deficiency than trans women when compared to others of their sex. FTMs were given hormones of the sex that has stronger bones and compared to the sex that has weaker bones. Likewise, MTFs were given hormones of the sex that has weaker bones and compared to the sex that has stronger bones.
In sum, the negative effects of puberty blockers on bone density are most apparent in transsexual kids who take them without also taking sex hormones that could help them retain and build bone strength.
Persistence, Desistance, and Sexual Orientation
Historically, most gender-dysphoric children who presented at gender clinics did not ultimately follow through on medical transition—they desisted from the transsexual path. In contrast, those who medically transitioned persisted.
Rising cultural awareness and acceptance of transgenderism has increased the rate of persistence. So has the use of puberty blockers.
In order to show the differences in persistence and desistance based on sexual orientation, I’ll use four studies. Two are from the Dutch clinic[li], and two are from the Toronto gender clinic[lii]. Almost all the data in these studies was collected before the social media revolution.
In these four studies, persisters were usually homosexual. Desisters had a more even mix of homosexuals and nonhomosexuals, but leaned toward the latter.
At the Dutch gender clinic, approximately 36–50% of females and 70% of males desisted[liii]. All, or virtually all, female desisters had nonhomosexual orientations. Approximately 44–60% of the male desisters had nonhomosexual orientations.
By contrast, those who persisted in their desire for medical transition were far more likely to be homosexual. In both of the Dutch studies examined here, virtually all persisters were homosexual[liv].
The other data on persistence and desistance in childhood gender dysphoria comes from Toronto, Canada. It’s split into two studies—a small one on females in which 22 of 25 (88%) desisted[lv], and a large, thorough one on males in which 112 of 129 (87%) desisted[lvi]. These desistance rates are much higher than those found in the Dutch studies.
Among the Canadian desisters, 81% of females[lvii] and 58% of males[lviii] (see footnote[1]) had a nonhomosexual orientation.
As in the Dutch studies, the Canadian studies showed that persisters were overwhelmingly homosexual. Among the three female persisters, two were homosexual. The third was asexual, reported no fantasies, and said he was “dead sexually”[lix]. Among the male persisters, 15 of 17 (88%) were homosexual[lx].
This association between sexual orientation and persistence/desistance works in the other direction, too. Depending on whether groups of children are homosexual or nonhomosexual, they have much different rates of persistence and desistance. Homosexuals are more likely to persist.
Both Canadian studies reported sexual orientation and whether it persisted for each individual case, which let me calculate precise persistence rates based on sexual orientation. A third of homosexual females persisted, but only 5% of nonhomosexual females did so[lxi]. The males showed a similar pattern: 24% of homosexual males persisted, but only 3% of nonhomosexual males did so[lxii].
The Dutch studies didn’t report the sexual orientation of all the patients, but they did report it for most of them. I used their figures for sexual fantasy to make similar estimates. Among females, approximately 87% of homosexuals and 6% of nonhomosexuals persisted. Among males, approximately 56% of homosexuals and 4% of nonhomosexuals persisted.
Taken altogether, these studies on childhood gender dysphoria back up the conventional wisdom among gender clinicians that early-onset gender dysphoria is usually of homosexual etiology. Almost all persisters had homosexual orientations. Among desisters, however, nonhomosexual orientations were the norm.
Their country of residence made a difference, too: most of the gender-dysphoric homosexuals in the Dutch clinics continued on to transition, but only a minority did so in the Toronto clinic. However, both clinics had single-digit percentages of persistence among nonhomosexuals of both sexes.
Although it’s impossible to know for sure ahead of time which individual children will benefit from medical transition[lxiii], these results show that sexual orientation is an important consideration in making the call about which children are likely to persist in their pursuit of medical transition.
The Dutch Protocol
In 1998, Dutch researchers published the first case report of puberty suppression in a gender-dysphoric child. He reported satisfaction with his subsequent masculinization and adjusted easily to a male social role[lxiv].
In the subsequent decade, clinicians at this gender clinic developed a selection process for suppressing puberty that came to be known as the “Dutch Protocol”. To qualify, children had to be at least twelve years of age and show physical signs of puberty. They also had to have:
Persistent gender dysphoria that began in early childhood
Greater dysphoria as puberty started
No co-occurring psychiatric issues that complicate the diagnosis or treatment process
Mental and social support during treatment
A thorough understanding of the effects and repercussions of hormones, surgery, and sex reassignment [lxv]
These Dutch researchers portrayed puberty suppression as “fully reversible” and argued that puberty blockers would give gender-dysphoric children and their parents time to carefully consider whether medical transition was right for them.
If careful consideration about the decision to transition did happen, though, there’s no way of knowing: all the children who started puberty blockers kept taking them, and they all ended up taking cross-sex hormones, too[lxvi].
Puberty Blockers Solidify Commitment to Medical Transition
The vast majority of children who go on puberty blockers for gender dysphoria ultimately continue onto cross-sex hormones.
Researchers from the Dutch clinic found that only 4.1% of MTFs and 0.7% of FTMs[lxvii] who started on blockers did not proceed to taking cross-sex hormones. Another Dutch study, one from a newer gender clinic, found that only 3.5% of patients who went on puberty blockers ultimately decided against going on cross-sex hormones[lxviii].
These gender-dysphoric Dutch youngsters weren’t alone in their tendency to continue onto cross-sex hormones after starting puberty blockers. American clinicians also report low levels of desistance after the start of puberty blockers.
Norman Spack, a Boston-based pediatric endocrinologist, reported in 2016 that of the hundreds of children to whom he gave puberty blockers, all continued onto cross-sex hormones—“no one changes their mind”, he said[lxix].
Johanna Olson, a Los Angeles-based pediatrician who specializes in transgender health, reported, “In my practice, I have never had anyone who was put on blockers, that did not want to pursue cross-sex hormone transition at a later point”[lxx].
This pattern holds for Brits too: gender clinicians working in the United Kingdom reported of their sample that “no patient within the sample desisted after having started on the [puberty] blocker”[lxxi]. By contrast, “90.3% of young people who did not commence the blocker desisted”[lxxii]. The webpage that originally stated these findings so clearly and succinctly has since been taken down.
These soaring persistence rates go far beyond what was seen before puberty suppression was offered by gender clinics.
Considering how gender patients view puberty blockers, however, this high rate of persistence is no surprise. Researchers have asked parents and patients about their views on puberty blockers and found that “all of them saw it as the first step in treatment”[lxxiii].
Social Transition Increases Commitment to the Cross-Gender Path
It’s becoming more common for gender-dysphoric children to undergo social gender transition at a young age, and those who do are more likely to follow through on medical transition down the line.
Dutch researchers found that whether male children dressed or socially presented as girls strongly predicted whether they persisted in the desire to transition[lxxiv]. Among male persisters, 43% already dressed or lived as a girl, but only 4% of male desisters did so. On the other hand, the rates of females dressing as boys didn’t vary much between persister and desister groups, and only one female, a persister, already lived as a boy[lxxv].
Recent research on children who socially transitioned at a young age suggests that most kids who socially transition before puberty will ultimately proceed onto puberty blockers and cross-sex hormones[lxxvi]. This study tracked 317 youth who first transitioned an average of five years prior and found the vast majority maintained nondefault gender identities: 94% of the kids still had binary transgender identities and 3.5% had nonbinary identities[lxxvii]. In contrast, only 2.5% had reverted to their default gender identities.
This high rate of persistence among social transitioners closely resembles the high rate of persistence among kids who start puberty blockers. Both interventions greatly increase the odds of staying on the transsexual path.
A Political Fight over an Empirical Question
Childhood gender transition has become a battleground in the ongoing culture war.
The two biggest camps on the anti-transition side are 1) social conservatives who feel a traditionalist imperative to preserve the gender binary and 2) a subset of feminists who prioritize sex over gender and regard gender as a method of oppressing females. Many of these social conservatives and feminists have ideological blinders that keep them from acknowledging some kids will benefit from avoiding their default puberty with medical transition.
People on the pro-transition side are often motivated by ideology, too. In particular, many are motivated by a fusion of Critical Theory and postmodernism most commonly known as “wokism” or “wokeness”[lxxviii]. Among its many flaws, wokism rejects the idea that liberal science is the best method for creating knowledge that corresponds to reality.
Another big group on the pro-transition side comprises well-meaning progressives. They often want trans people to be treated well and see childhood gender transition as part of that. These progressives are likely to go along with whatever they see transgender people advocating for.
This is a problem: prepubescent gender-dysphoric youth are mostly of homosexual etiology, but many of the fiercest advocates for youth gender transition are autohet transsexuals who transitioned as adults and wish they had been able to transition younger.
Since autoheterosexual and homosexual orientations are opposites in both gender and direction, it is unlikely that late-transitioning autohet transsexuals have special insight into the experiences of children with early-onset homosexual gender dysphoria. These are fundamentally different situations that should not be conflated.
The intense political battle over youth gender transition makes it harder for clinicians to do their job of answering the practical questions at the heart of this issue:
Is it possible to know which kids will benefit from medical transition and which will be harmed by it?
If so, how can we tell them apart?
These questions are ultimately empirical in nature. The real, workable answers will come from clinical experience and scientific study, not ideology.
Can Kids Consent to Transsexualism?
Can kids meaningfully consent to going down the transsexual path?
Skipping default puberty by going on puberty blockers and cross-sex hormones renders a child sterile, and those who remove their gonads become hormonally dependent upon the medical industry for the rest of their lives.
Can a fourteen-year-old kid fully grasp the consequences of this decision? What about a ten-year-old kid?
To make matters worse, public understanding of transgenderism and transsexualism is in a truly sorry state. For example, it is not yet common knowledge that there are two fundamentally different types of transgenderism.
If adults lack such basic, rudimentary knowledge, how much can the kids know? In this state of ignorance, can kids even begin to make informed decisions about transition?
Kids are also not being told about the limitations of transsexualism. It is not currently possible for humans to change sex. Kids ought to know that medical transition helps a person more closely resemble the other sex, but it does not literally make them that sex.
Youth gender transition is backed by several large medical organizations and it’s often portrayed as a safe, efficacious treatment. In truth, the efficacy of youth medical transition is still unknown. It’s important for gender-dysphoric kids and their parents to know that medical transition remains an experimental treatment, and there is no way to know for sure whether any particular individual will ultimately benefit from medical transition.
Giving Cross-Sex Hormones Earlier as Harm Reduction
The original justification for using puberty blockers in transsexual youth was to give them time to think through the decision to transition. But studies show that almost all transsexual youth who start puberty blockers continue onto cross-sex hormones, so the original justification does not hold up.
Portrayal of puberty blockers as safe and reversible is also misleading. If a child takes blockers to forestall puberty and decides to go off of them and resume their natal puberty, it is not as though nothing has happened.
Puberty blocker monotherapy in pubescent kids stalls bone growth during a developmental stage in which bone strengthening is typically rapid and pronounced. Stripped of hormones, people are more susceptible to developing neurological issues suggestive of mitochondrial dysfunction such as joint and muscle pain, cognitive impairment, and mental health issues—all of which lower quality of life.
Given that puberty blocker monotherapy causes such intense side effects and is used primarily to forestall puberty until the calendar says a kid can consent to taking cross-sex hormones, this use of puberty blockers should be reconsidered.
I have a proposal. Instead of giving puberty blocker monotherapy to juvenile transsexuals, give them what they actually want: cross-sex hormones. These could be administered instead of puberty blockers, or in combination.
This proposal might seem extreme, but is giving pubescent kids cross-sex hormones any more extreme than several years of puberty blocker monotherapy followed by giving them those same hormones?
One potential snag to this approach is that it’s probably less feasible for FTMs. Females hit puberty earlier than males and testosterone is arguably more intense than estrogen, so cross-sex hormone administration after the onset of puberty is less risky for MTFs.
In general, I am quite wary of youth gender transition. It is still new and its long-term efficacy unknown.
I also doubt most gender clinicians working today can identify the kids who would benefit from medical transition reliably enough to make the enterprise of youth medical transition ethical overall.
In addition, transsexualism studies have low follow-up rates that call into question the validity of the findings, and there are more detransitioners with each passing day.
However, I believe some kids stand to benefit from youth medical transition. I don’t know the proportion or how to reliably identify them, but some surely exist. For the subset of kids who stand to benefit from medical transition, which option is better?
Having a cross-sex puberty at a developmentally normal age
Being held in developmental stasis by a drug with global side effects and lagging behind peers for several years, then going through cross-sex puberty
In both scenarios, the kids end up permanently sterile. In both, they consent to experimental medical treatment before they are truly able to.
However, if virtually all gender-dysphoric kids who start puberty blockers ultimately go on to take cross-sex hormones anyway, isn’t it likely that puberty blocker monotherapy is causing a great deal of harm for very little benefit?
In Sum:
The onset of puberty generally arrives before people are old enough to legally consent to serious, irreversible medical interventions. To get around this issue, clinicians sometimes give gender-dysphoric minors puberty blockers to halt puberty until the calendar deems them capable of consent.
Although youth gender transition is an experimental treatment, recipients of this treatment are not being tracked long-term. This hinders the ability of clinicians to improve transgender health care. Without data on treatment outcomes, it will not be possible to arrive at optimal clinical practices. This ignorance will harm future generations of trans people.
Sex hormones impact the whole body by acting at receptor sites in tissues and organs. They also act through receptor sites in mitochondria—organelles found in nearly all human cells that produce the chemical energy which keeps us alive.
Estradiol helps maintain mitochondrial health. Devoid of sex hormones, people are more susceptible to developing mitochondrial dysfunction. Puberty blockers strip the body of sex hormones, so their use contributes to systemic mitochondrial dysfunction. Since puberty blocker monotherapy is so detrimental, it might be less harmful to give cross-sex hormones earlier, at a more developmentally appropriate time.
GnRH agonists (puberty blockers) have intense, widespread side effects. People on these drugs commonly report serious neurological or physical issues such as memory loss, neuroticism, headaches, fatigue, joint pain, muscle pain, or bone deterioration. Puberty blocker monotherapy weakens the bones of transsexual minors by stalling bone growth during a developmental phase in which bone growth and strengthening is generally rapid.
Prior to the social media revolution, persistence and desistance rates among dysphoric youth differed drastically based on sexual orientation. Children whose wish for medical transition persisted were overwhelmingly homosexual, while those who desisted were mostly nonhomosexual.
Puberty blockers solidify commitment to gender transition. Social transition does, too. The transsexual path involves highly consequential surgeries and lifelong reliance on synthetic hormones, so social transition and puberty blockers are not neutral interventions.
Ideologically motivated stances on youth gender transition are unlikely to reflect what is actually best for transsexual youth. It’s still unknown whether it is possible to adequately differentiate kids who would be harmed by medical transition from those who would achieve a net benefit. Clinical experience and empirical studies will ultimately provide insight into the best practices for dealing with juvenile gender dysphoria. Ideology will not.
[1] This study of juvenile male gender dysphoria sorted bisexuals and homosexuals into the same group, so I used the list of individual cases provided in the supplementary materials to sort by homosexual and nonhomosexual instead. The study recorded sexual orientation using the Kinsey Scale, a 0–6 scale in which zero is fully heterosexual and six is fully homosexual. I sorted into the homosexual group those who were Kinsey sixes for sexual fantasy, as well as those who were Kinsey fives for sexual fantasy and Kinsey sixes for sexual behavior. All the rest were sorted into the nonhomosexual group.
[i] Byne et al., “Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder,” 763.
[ii] Byne et al., 764.
[iii] Coleman et al., “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8,” S46.
[iv] Kreukels et al., “A European Network for the Investigation of Gender Incongruence.”
[v] McEwen and Milner, “Understanding the Broad Influence of Sex Hormones and Sex Differences in the Brain”; Weiser, Foradori, and Handa, “Estrogen Receptor Beta in the Brain.”
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[xxvii] Hara et al., “Presynaptic Mitochondrial Morphology in Monkey Prefrontal Cortex Correlates with Working Memory and Is Improved with Estrogen Treatment.”
[xxviii] Hara et al., 489.
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[xxxiv] Nolbert, Wells, and Hussein, 38–39.
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[xxxviii] Jewett, “Women Fear Drug They Used To Halt Puberty Led To Health Problems.”
[xxxix] Marrs, “Lupron, Estradiol and the Mitochondria: A Pathway to Adverse Reactions.”
[xl] Millican, “They Say Lupron Is Safe.”
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"People in favor of this approach argue that suppressing puberty will give the children and their clinicians more time to decide whether medical transition is right for them. In reality, however, almost all children who start taking puberty blockers for their gender issues will continue onto cross-sex hormones at a later date."
This is the most solid point you make here, I think: the idea that puberty blockers are a way to buy time to make a decision seems to be a convenient fiction, used to placate people who don't want to see minors transitioning, whether because they oppose transition in general or because they don't think minors are qualified to make such decisions about their own health.
In reality, someone who chooses to go on puberty blockers is someone who has already made up their mind to transition, and the role puberty blockers actually serve is to avoid the unwanted effects of natal puberty until they're allowed to start cross-sex hormones. You could call it harm reduction, but I think it makes more sense to call it preventive treatment: an adolescent who's denied puberty blockers will go on to become an adult who has to live with some unwanted bodily changes forever, and who can only correct other changes with surgery that's much riskier and more expensive than blockers.
"Puberty happens before kids are mature enough to truly grasp the implications of their decision to transition."
First, this is overstated - there's very little evidence that minors are actually unable to grasp the implications of their decisions. That's mostly an unquestioned assumption used to override decisions that adults don't like. And we acknowledge that in other cases where we decide that the minor's long-term health interests outweigh the child-rearing interests of the adults around them: for example, minors are often able to give legal consent for decisions about their own reproductive health, mental health, or addiction treatment at a younger age than other medical decisions.
Second, it goes both ways - the effects of _not_ going on puberty blockers are every bit as serious, permanent, and life-changing as the effects of going on them, if not more so. A bias toward inaction is just a bias toward one set of consequences rather than the other. If it were truly the case that minors were incapable of making these decisions, then the proper response would be to take the decision out of minors' hands completely and let the adults around them decide whether or not they go through natal puberty, rather than only second-guessing them when they want to avoid it.
"There are two aspects of juvenile transsexualism, however, that I feel confident enough about to say something here. One is the need to curtail the use of puberty blocker monotherapy because being hormonally sexless wreaks havoc on the human body."
The age of puberty varies between individuals; some people are "early bloomers" and others are "late bloomers". To the extent that puberty blocker monotherapy is used to shift the onset of puberty within the typical range, what reason is there to believe that it "wreaks havoc" beyond what we already consider normal?
"Puberty Blockers Solidify Commitment to Medical Transition"
This bold assertion in a heading doesn't seem to be supported by the text that follows. You're making a claim about causality, but simply observing that minors who go on puberty blockers for gender dysphoria usually continue onto cross-sex hormones does _not_ tell us anything about causality.
By analogy, we might observe that the vast majority of people who take ibuprofen several days in a row for a toothache continue on to get a root canal, but it'd be a mistake to conclude that ibuprofen solidifies the commitment to get a root canal. Having a toothache is what leads to both the ibuprofen and the root canal; people choose the ibuprofen first because it's more accessible, or less of a commitment, but most of them will need a root canal anyway, because people generally aren't wrong about having a toothache, and ibuprofen doesn't address the underlying issue.
"Social Transition Increases Commitment to the Cross-Gender Path"
Exactly the same problem here. Your conclusion that "Both interventions greatly increase the odds of staying on the transsexual path" doesn't follow from observations like "whether male children dressed or socially presented as girls strongly predicted whether they persisted in the desire to transition": you've overlooked the likelihood that the male children who dress as girls despite social expectations were just more gender dysphoric in the first place.
"However, I believe some kids stand to benefit from youth medical transition. I don’t know the proportion or how to reliably identify them, but some surely exist."
What do you think of Kay Brown's conclusion (https://sillyolme.wordpress.com/2011/02/28/age-of-innocence/) that "the developmental process, what ever it is, for desistors, is finished by age 14. If a gender atypical 14 year old is still gender dysphoric and wishes to begin hormones and transition, we can be reasonably certain that he or she will not change his/her mind later. Thus, based on the evidence, we can safely begin such interventions."
I do think you underestimate the benefits of early transition for male-attracted mtf patients. It’s difficult enough to nab a good husband as a cis woman these days — and losing years to post-puberty transition and being masculinised by testosterone doesn’t help.
As finding a husband was never in the cards for your group, timing of transition doesn’t really matter — the outcome is the same. Husband and kids were never a part of the scenario no matter how early the transition.