The impact of suppressing puberty on neuropsychological function: A review

Puberty blockers for gender dysphoria in youth: A systematic review and meta-analysis

AIM

Gender dysphoria (GD) refers to the psychological distress associated with the incongruence between one's sex and one's gender identity. To manage GD, individuals may delay the development of primary and secondary sex characteristics with the use of puberty blockers. In this systematic review, we assess and summarise the certainty of the evidence about the effects of puberty blockers in individuals experiencing GD.

METHODS

We searched Medline, Embase, PsychINFO, Social Sciences Abstracts, LGBTQ+ Source and Sociological Abstracts from inception to September 2023. We included observational studies comparing puberty blockers with no puberty blockers in individuals aged <26 years experiencing GD, as well as before-after and case series studies. Outcomes of interest included psychological and physical outcomes. Pairs of reviewers independently screened articles, abstracted data and assessed risk of bias. We performed a meta-analysis and assessed the certainty of a non-zero effect using the grading of recommendations assessment, development and evaluation (GRADE) approach.

RESULTS

We included 10 studies. Comparative observational studies (n=3), comparing puberty blockers versus no puberty blockers, provided very low certainty of evidence on the outcomes of global function and depression. Before-after studies (n=7) provided very low certainty of evidence addressing gender dysphoria, global function, depression, and bone mineral density.

CONCLUSIONS

There remains considerable uncertainty regarding the effects of puberty blockers in individuals experiencing GD. Methodologically rigorous prospective studies are needed to understand the effects of this intervention.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42023452171.

Iatrogenic Gender Dysphoria and Harm Cycle in Gender Affirming Care

In recent years, there has been a significant increase in cases of gender dysphoria among children and adolescents. Iatrogenesis, as a result of early social and medical transitions in the gender-affirming care model, has contributed to this rise, leading to a group of cases that could be described as 'iatrogenic gender dysphoria.' Iatrogenesis also causes potential harm in the medical and surgical treatments of these cases. Thus, gender dysphoria cases are effectively encircled by an iatrogenic harm cycle, from development to treatment. Pressures that restrict academic freedom in the field of gender medicine, political influences, issues of 'spin' in publications related to the gender-affirming care model, and misleading or exaggerated statements made by some clinicians to the public also contribute to this harm cycle. This article discusses the role of iatrogenesis in the increase of gender dysphoria cases and its effects within the harmful cycle surrounding these cases.

Toward Evidence-Based and Ethical Pediatric Gender Medicine

This Viewpoint discusses the need for clinicians to conduct thorough research on the risks and benefits of gender-affirming care so that lawmakers and judges do not make decisions on such care without evidence.

Critiques of the Cass Review: Fact-Checking the Peer-Reviewed and Grey Literature

The Cass Review's final report, published in April 2024, made recommendations to the UK's National Health Service regarding structuring of services for minors with gender-related distress. It recommended cautious use of hormonal interventions in this population and use of research protocols. Some clinician-researchers disagree with the Cass Review's recommendations and have written critiques. A critique of the Cass Review posted on Yale Law School's website in July 2024 has received extensive media coverage. Its references identified three other critiques. In these papers, there were multiple claims that were incorrect or that lacked essential clarification/contextualization. These claims involved (1) the Cass Review's contents and processes; (2) the pediatric transgender healthcare evidence base; (3) existing clinical practice guidelines, including claims that there is international medical consensus; (4) evidence-based medical practice and guideline development; and (5) conclusions regarding the validity of the Cass Review's findings. The Cass Review's careful, balanced investigations and judgments were a comprehensive, evidence-based response to the controversies in this pediatric clinical arena. Recently-published critiques of the Review have contained incorrect or inadequately contextualized claims. Because accurate information about medical interventions is essential to informed consent, it is important to correct errors in potentially influential publications.

Discontinuing hormonal gender reassignment: a nationwide register study

BACKGROUND

With increasing numbers of people seeking medical gender reassignment, the scientific community has become increasingly aware of the issue of detransitioning from social, hormonal or even surgical gender reassignment (GR). This study aimed to assess the proportion of patients who discontinued their established hormonal gender transition and the risk factors for discontinuation.

METHODS

A nationwide register-based follow-up was conducted. Data were analysed via cross-tabulations with chi-square statistics and t tests/ANOVAs. Multivariate analyses were performed via Cox regression, which accounts for differences in follow-up times.

RESULTS

Of the 1,359 subjects who had undergone hormonal GR in Finland from 1996 to 2019, 7.9% discontinued their established hormonal treatment during an average follow-up of 8.5 years. The risk for discontinuing hormonal GR was greater among later cohorts. The hazard ratio was 2.7 (95% confidence interval 1.1-6.1) among those who had accessed gender identity services from 2013 to 2019 compared with those who had come to contact from 1996 to 2005. Discontinuing also appeared to be emerging earlier among those who had entered the process in later years.

CONCLUSIONS

The risk of discontinuing established medical GR has increased alongside the increase in the number of patients seeking and proceeding to medical GR. The threshold to initiate medical GR may have lowered, resulting in a greater risk of unbalanced treatment decisions.

TRIAL REGISTRATION NUMBER (TRN)

Not applicable (the paper does not present a clinical trial).