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New Study Reveal shocking rates of attempted suicide among trans-adolescents.
30% of transgender adolescents have attempted suicide at some time. 51% suffer from depression and many engage in self harm.
New treatments are being used. However; at what cost?
What Are Puberty Blockers?
Recent conservative legislation has targeted a class of drugs used to treat transgender adolescents. But what do these drugs actually do?
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By Lena Wilson – The New York Times
May 11, 2021
Lately, puberty blockers have become a subject of debate in state legislatures, as lawmakers across the country introduce bills to limit health care options for transgender youth. Legislators in Arkansas already passed such a law, although Gov. Asa Hutchinson vetoed it last month. Arkansas conservatives argued that “the risks of gender transition procedures far outweigh any benefit at this stage of clinical study on these procedures.” But medical experts say that’s not the case.
Among the significant benefits of puberty blockers are a reduction in suicidal tendencies, which are often high in transgender adolescents, and a reduced need for expensive gender-affirming operations as adults. But while puberty blockers are commonly referred to as “fully reversible,” more research is needed to fully understand the impact they may have on certain patients’ fertility. There is also little known about the drugs’ lasting effects on brain development and bone mineral density.
Transgender youth have been the focus of new laws in states including Mississippi and Idaho, and pending in many others, designed to restrict their participation in sports — but this debate is largely separate from the discussion of puberty blockers.
Because the use of puberty blockers in transgender kids is still relatively new, the information is developing.
Here is a roundup of what experts know so far.
What are puberty blockers?
Puberty blockers are medications that suppress puberty by halting the production of estrogen or testosterone. They can stop transgender kids from experiencing the effects of puberty that may not align with their gender identities. Medically, the class of medications are called gonadotropin-releasing hormone agonists, or GnRH agonists. They are approved by the Food and Drug Administration to treat precocious puberty — puberty occurring at an unusually early age — so when they are prescribed to treat transgender youth, it’s considered an off-label use.
“Off-label,” the American Academy of Pediatrics noted in a 2014 statement, “does not imply an improper, illegal, contraindicated or investigational use” — it merely refers to the process of F.D.A. approval.
The medications may be given as shots in a doctor’s office every one, three or six months, or as an implant which lasts for about a year. Dr. Jessica Kremen, a pediatric endocrinologist for Boston Children’s Hospital’s Gender Multispecialty Service, noted that patients and families may prefer the convenience of the implants or six-month shots.
“It depends a lot on what is obtainable through a patient’s insurance,” Dr. Kremen said. Insurance companies are reluctant to cover off-label drug treatments, and implants can run up to approximately $45,000 per implant out of pocket, while shots cost can cost thousands of dollars per dose.
“That often determines which form we ended up using,” Dr. Kremen said. “But they all work well, as long as you administer them on time.”
How do they work?
Typically, in puberty, gonadotropin-releasing hormone helps to produce follicle-stimulating hormone (FSH) and luteinizing hormone (L.H.). In people assigned female at birth, these hormones prompt the ovaries to make estrogen, which promotes processes like breast growth and menstruation. In people assigned male at birth, they prompt the testes to make testosterone, which promotes processes like facial hair growth and a deepening of the voice.
Puberty blockers disrupt the production of FSH and L.H., therefore blocking the production of estrogen or testosterone. As a result, transgender adolescents do not continue to develop unwanted secondary sexual characteristics — transgender boys do not develop breasts and transgender girls do not develop facial hair, for example.
Puberty blockers do not stop an early stage in sexual maturation called adrenarche, which can cause acne, the growth of underarm and pubic hair and body odor.
Who can get puberty blockers?
Although parents might think they should start puberty blockers very young, so that a child never has to experience any physical changes associated with the unwanted gender, experts say it’s better to wait at least until the early stages of puberty have started. Dr. Stephen Rosenthal, medical director of the child and adolescent gender center for U.C.S.F. Benioff Children’s Hospitals, was a co-author of the Endocrine Society’s 2017 guidelines for transgender health care. He recommended starting puberty blockers when breast budding or the enlargement of the testes has begun, at the earliest.
That’s because Dr. Rosenthal does not recommend puberty blockers for prolonged use outside of the normal window of puberty. They restrict the functioning of the gonads, which may lead to adverse health effects. The longer blockers are used past the typical start of puberty — generally age 14, at the latest — the greater the possible risk.
When blockers are initiated in the early stages of puberty, Dr. Rosenthal typically suggests that his patients stop using them by age 14. At that point, patients, with their families and their doctors, can determine whether to introduce hormones that help them develop according to their gender identity or resume puberty in the gender assigned at birth.
Dr. Rosenthal further recommended that before starting blockers, children be evaluated by a mental health professional and determined to have gender dysphoria. He said families should also undergo a thorough process of informed consent, during which they are educated about the potential effects of blocking puberty — including adverse ones.
The World Professional Association for Transgender Health’s guidelines for medical care suggest that “before any physical interventions are considered for adolescents, extensive exploration of psychological, family and social issues should be undertaken.” Professionals emphasized mental health care as an integral part of the process.
What are the benefits?
Treatment with puberty blockers may improve the mental health of transgender adolescents, who are at high risk for suicide. A 2020 study found lower odds of lifetime suicidal ideation in transgender adults who wanted to take puberty blockers and were able to access this treatment. Another recent study showed similarly positive effects: transgender adolescents receiving puberty blockers had less “emotional and behavioral problems” than transgender adolescents recently referred to care, and also reported rates of self-harm and suicidality similar to those of their non-transgender peers. A 2020 study of 50 transgender adolescents indicated that puberty blockers and gender-affirming hormone treatments, or both, could positively impact quality of life and decrease depression and suicidal ideation. A 2014 study found that 55 young transgender adults who used puberty blockers, took gender-affirming hormones and had gender confirmation surgeries were able to “resolve” their gender dysphoria and showed overall well-being “in many respects comparable to peers.”
Because puberty blockers halt the development of secondary sexual characteristics, transgender adolescents who take them before gender-affirming hormones may also be able to avoid future gender-affirming procedures. For instance, transgender men who don’t develop breasts wouldn’t have reason to have mastectomies, while transgender women who don’t develop masculine facial features might no longer choose to have facial feminization surgery.
The Push to Restrict Rights for Young Transgender People
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A growing trend. Measures that could transform the lives of young transgender people are at the center of heated political debate across America. Here is how some states are approaching the subject:
Texas. In October, Texas became the most populous state to bar transgender girls from participating in girls’ sports at public schools. Gov. Greg Abbott also issued an order to conduct child abuse investigations against those providing certain medical treatments to transgender children. A court ruling later stopped the order from being applied.
Arkansas. Last April, Arkansas enacted a law, the first of its kind in the nation, barring physicians from administering hormones or puberty blockers to transgender people younger than 18. It is now on pause because of a legal challenge from the American Civil Liberties Union.
Indiana. Gov. Eric Holcomb, a Republican, vetoed a bill that would have banned transgender girls from competing in school-sanctioned girls’ sports. The governor said the bill, known as H.E.A. 1041, would likely have been challenged in court.
Utah. A day after the decision in Indiana, Gov. Spencer Cox, also a Republican, vetoed a similar bill that would have barred young transgender athletes from participating in girls’ sports. Republican legislators subsequently voted to override the veto and enacted the legislation.
Kentucky. Gov. Andy Beshear, a Democrat, vetoed a bill that would prevent transgender female athletes from playing on girls’ sports teams in middle school and high school. The State Legislature, which is dominated by Republicans, is expected to override the veto.
Alabama. Gov. Kay Ivey signed a law banning medical care for transgender youth who are transitioning. She also approved legislation requiring students to use restrooms and locker rooms in line with the sex listed on their original birth certificates and restricting discussions on gender and sexuality in kindergarten through fifth grade.
Other states. Since 2019, lawmakers have introduced bills seeking to bar transgender youths from joining school sports teams consistent with their gender identities. They have become law in Alabama, Arkansas, Florida, Idaho, Iowa, Mississippi, Montana, South Dakota, Tennessee, Texas and West Virginia.
What are the risks?
Puberty blockers are largely considered safe for short-term use in transgender adolescents, with known side effects including hot flashes, fatigue and mood swings. But doctors do not yet know how the drugs could affect factors like bone mineral density, brain development and fertility in transgender patients.
The Endocrine Society recommends lab work be done regularly to measure height and weight, bone health and hormone and vitamin levels while adolescents are taking puberty blockers.
A handful of studies have underscored low bone mineral density as a potential issue, though a 2020 study posited that low bone mineral density may instead be a pre-existing condition in transgender youth. Treatment with gender-affirming hormones may theoretically reverse this effect, according to Endocrine Society guidelines.
The impact of puberty blockers on brain development is similarly hazy. The Endocrine Society guidelines point to two studies: A small one published in 2015 showed that the drugs did not seem to impact executive functioning (cognitive processes including self-control and working memory), while a 2017 study of rams treated with GnRH agonists suggested chronic use could harm long-term spatial memory. (Of course, rams are not humans.)
The effects of puberty blockers are often referred to as “fully reversible,” including in both the Endocrine Society and WPATH guidelines, because of evidence showing that girls treated for precocious puberty were still able to undergo normal puberty and have children later in life.
Halting puberty at its onset and then later starting gender-affirming hormones — a typical course for some transgender adolescents — may affect the ability to have children, she said. The Endocrine Society advises clinicians to counsel patients on “options for fertility preservation prior to initiating puberty suppression in adolescents.”
It is also worth noting that Lupron, one of the drugs widely used as a puberty blocker, has been reported to have long-term adverse effects in women who used it to treat precocious puberty. Women have reported issues including depression, bone thinning and chronic pain.
Puberty blockers may also impact future gender-affirming surgeries for transgender women. A recent study showed that transgender women who began puberty blockers at the start of puberty were 84 times more likely to require abdominal surgery if they wanted to pursue gender-affirming surgery. Because tissue from the penis and testes is used to construct a neovagina, and puberty blockers prevent the growth of those organs, material from the colon or omentum may need to be used.
An in-depth conversation detailing puberty blocker treatment and all its potential effects is an essential part of any transgender adolescent’s care. Specialists are eager for more research, but for now, they say the apparent benefits outweigh the hypothetical risks.
“Medications are rarely without side effects,” Dr. Kremen said. “That is usually not enough of a reason to allow a child, who is telling you that they’re extremely distressed by the pubertal changes that they’re seeing, to continue going through puberty.”
“Knowing what we do know, these medications have enormous benefits for the population that we care for,” she added.
Lena Wilson is a project manager at The New York Times and a freelance writer covering film, TV, technology and lesbian culture. @lenalwilson
Transgender surgeries can easily cost the patient $100,000 or more. And, those are just the medical costs.
So, the debates continue to rage. We can’t really fault the doctors who, treating young patients who inflict self-harm on themselves and/or attempt suicide, help the patients out of their distress and into a happier life.
Yet, there is any amount of scientific evidence to support conditions such as Kallman syndrome, where the individual does not go through a normal puberty due to insufficient hormonal growth. Individual born with this condition frequently suffer from osteoporosis and are infertile.
Development of the large bones and the reproductive tract occur during this time in a person’s life. To chemically avoid this period of mental and physical growth may have consequences that are far reaching for the individual. Consequences that few, if any, teenagers are capable of grasping.
What did transgender people do 50 to 100 years ago? 200 years ago? Did they all commit suicide? Is there any research on this? If lawmakers have long concluded that 21 years is the legal age to drink alcohol; why is 13 or 14 years a proper time to make lifetime decisions not only about one’s sexuality but modifications of one’s entire body? Does this make sense?
It is easy to say I don’t understand because I don’t have a transgender child. True, but I have a child who was a teenager and I have been a teenager. Also, I have taught teenagers. These can be tough years. Uncomfortable years. Are we promoting serious body modifications in order to avoid discomfort? What is wrong with having the individual wait until they are 18? So they can avoid a mastectomy? Removal of breast tissue is the least complicated of surgeries the individual will go through if they want to become fully male. How about lifetimes on hormone therapies? How many studies have been done that tell menopausal women to get off hormone replacement therapy? That the pills cause cancer?
The human brain is not adult size until about age 14. True adult judgement comes along very gradually a long time after that.
University of Rochester Medical Center
The rational part of a teen’s brain isn’t fully developed and won’t be until age 25 or so.
In fact, recent research has found that adult and teen brains work differently. Adults think with the prefrontal cortex, the brain’s rational part. This is the part of the brain that responds to situations with good judgment and an awareness of long-term consequences. Teens process information with the amygdala. This is the emotional part. https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=1&ContentID=3051#:~:text=The%20rational%20part%20of%20a,cortex%2C%20the%
Once these extreme body modifications are done, it is unlikely they can be undone. It’s not like getting a tattoo or dying your hair pink.
Not the same, not at all.