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They Paused Puberty, but Is There a Cost?

In 2022, New York Times writers Megan Twohey and Christina Jewett co-wrote a scaremongering article on puberty blockers for gender diverse youth that culminated in a 2023 newsroom revolt against Times leadership.

The article promoted and popularized several anti-trans talking points about gender affirming care for minors, including “bone density” and “low quality evidence.”

The piece is part of a strategy by anti-trans organizations like Genspect to get FUD propaganda (fear, uncertainty, and doubt) about gender affirming care into mainstream media. Focusing on uncommon side effects and unknown risks is a long-used pretense to restrict or ban similar healthcare like contraception and abortion, especially for minors.

Background

The story is about “emerging evidence of potential harm” and the “long-term physical effects and other consequences” of Lupron and other medications that can manage onset of puberty. Any drug carries a risk of side effects, which the US Food and Drug Administration (FDA) tracks via adverse event reports. FDA approved Lupron for central precocious puberty in 1993. It has since been used for trans and gender diverse youth experiencing unwanted puberty. Doctors have wide latitude to use approved drugs “off label,” including use to delay puberty for trans and gender diverse youth.

Several years earlier, Jewett began reporting on cisgender people who believe puberty blockers which they took as minors led to short- and long-term adverse side effects. Children whose puberty starts at 5 to 8 years old often face social problems, and those capable of pregnancy are at higher risk of sexual harassment and assault. Doctors work with parents to weigh the risks and benefits before getting informed consent. As with any medical treatment, some people will be harmed more than they were helped.

Headlines used for the story include:

  • They Paused Puberty, but Is There a Cost?
  • Puberty Blockers Can Help Transgender Youth. Is There a Cost?

Below are anti-trans talking points that were promoted and popularized via this article.

Bone density

Puberty involves a release of hormones that affect bone deposition throughout the body. Puberty blockers affect that process, so bone health is monitored in adolescent patients, usually with a baseline measurement before treatment followed by scheduled measurements.

One of the three young people profiled had to stop puberty blockade due to done density issues. While this is a well-known risk and uncommon side effect, it can usually be monitored and managed. Having to stop hormone blockade altogether due to bone density is rare.

Via USPATH/WPATH:

The anecdote provided of an adolescent who began, and then stopped pubertal suppression due to bone density loss lacks important details, including age and pubertal stage at initiation of puberty blockers, length of time on blockers, baseline bone density (“Z-score”), and whether the bone density comparison was made to identified gender or birth-assigned sex. Additional important information not provided includes calcium intake, and vitamin D intake and level, as well as level of physical activity, all of which play a substantial role in maintenance of bone mineral density.

“Low-quality evidence”

Jewett and Twohey also parrot the “low-quality evidence” claim put forth by anti-trans activists, based on a scale devised by Gordon Guyatt. Federal judge Sarah E. Geraghty rejected these claims in a 2023 Georgia case where anti-trans activists Paul Hruz, Michael Laidlaw, and James Cantor testified against Yale University professor of pediatrics Meredithe McNamara:

The undisputed record shows that clinical medical decision-making, including in pediatric or adolescent medicine, often is not guided by evidence that would qualify as “high quality” on the scales used by Defendants’ experts. 30 (Doc. 70-1, McNamara Decl. ¶¶ 23–28; Tr. 74:11–75:1 (McNamara Testimony); Tr. 133:614 (Hruz Testimony).) In fact, the record shows that less than 15 percent of medical treatments are supported by “high-quality evidence,” or in other words that 85 percent of evidence that guides clinical care, across all areas of medicine, would be classified as “low-quality” under the scale used by Defendants’ experts. (Doc. 70-1, McNamara Decl. ¶ 25; Tr. 74:11–75:1.) Defendants do not refute Dr. McNamara’s testimony on this point, and indeed they “concede” that “low-quality” evidence “can be considered.” 31

Geraghty (2023) [emphasis mine]

Geraghty also noted the obvious biases of Hruz, Laidlaw and Cantor:

Defendants’ experts’ insistence on a very high threshold of evidence in the context of claims about hormone therapy’s safety and benefits, and on the other hand their tolerance of a much lower threshold of evidence for claims about its risks, the likelihood of desistance and/or regret, and their notions about the ideological bias of a medical establishment that largely disagrees with them. That is cause for some concern about the weight to be assigned to their views, although the Court does not doubt that those they express are genuinely held.

(“Dr. [Paul] Hruz fended and parried questions and generally testified as a deeply biased advocate, not as an expert sharing relevant evidence-based information and opinions. I do not credit his testimony.”); Eknes-Tucker v. Marshall, 603 F. Supp. 3d 1131, 1142–43 (M.D. Ala. 2022) (explaining that the court gave Dr. James Cantor’s “testimony regarding the treatment of gender dysphoria in minors very little weight”); C. P. by & through Pritchard v. Blue Cross Blue Shield of Illinois, No. 3:20-CV-06145-RJB, 2022 WL 17092846, at *4 (W.D. Wash. Nov. 21, 2022) (noting that it was a “close question” as to whether Dr. Michael Laidlaw was qualified to testify about the medical necessity of gender-affirming care because he has treated only two patients with gender dysphoria and has done no original research on gender identity).

Geraghty (2023)

Mentioned

  • Emma Basques (gender diverse youth), Emma’s doctor, and parents Cherise and Arick
  • Jacy Chavira  (gender diverse youth)
  • [unnamed] (gender diverse youth and parent)
  • Norman Spack, endocrinologist
  • Sundeep Khosla, bone researcher
  • Hilary Cass, pediatrician
  • Catherine Gordon
    • We were surprised to see reference to a subjective statement from Dr. Catherine Gordon, MD regarding “getting behind” on bone density, and we question whether this comment was taken out of context. Dr. Gordon is a long-standing advocate for trans youth care, and in her June 2022 single-author commentary published in Pediatrics, she stated that, “The duration of pubertal suppression with gonadotropin hormone releasing hormone agonists varies, but can extend up to 4 years for younger patients who are not able to provide consent until age 16 for receipt of gender-affirming therapy. Puberty blockers represent an invaluable intervention for these children and adolescents, to reduce anxiety and ‘buy time’ until final decisions can be made about gender assignment.” A subsequent commentary co-authored by Dr. Gordon and published in November 2022 in JAMA Open Access stated, “Concerns about skeletal losses become less significant in an adolescent with active suicidal ideations. Although the significance of the risks may be unclear, there is strong evidence regarding the benefits of GnRHa in transgender youth: it can be a life-changing and lifesaving treatment for a vulnerable population who is at high risk for anxiety, depression, and suicide.”
  • Peggy Cohen-Kettenis, psychologist
  • WPATH
  • Walter Meyer, pediatric endocrinologist and psychiatrist
  • Jenn Burleton
  • American Academy of Pediatrics and the international Endocrine Society, which in 2017 had described the limited research on the effects of the drugs on trans youth as “low-quality.” 
  • more than 50 doctors and academic experts around the world
  • Models: Dutch, US, UK, Sweden, Finland

Supporters

Critics

  • WPATH and USPATH
  • GLAAD
  • Melissa Gira Grant of New Republic
  • Erin Reed of Erin in the Morning
  • Kate Sosin of 19th News
  • Molly Redden of HuffPost
  • Trans author Jennifer Finney Boylan
  • Christina Cauterucci, Jules Gill-Peterson, and Bryan Lowder in Slate
  • Kaiyti Duffy in Teen Vogue
  • Erin Rook in LGBTQ Nation
  • AJ Eckert in Science Based Medicine
  • Trans journalist Dawn Ennis
  • Child psychiatrist Jack Turban

References

Twohey, Megan; Jewett, Christina (November 14, 2022). They Paused Puberty, but Is There a Cost? New York Times https://www.nytimes.com/2022/11/14/health/puberty-blockers-transgender.html [archive]

WPATH / USPATH (November 22, 2022). USPATH and WPATH Respond to NY Times Article “They Paused Puberty, But Is There a Cost?” published on November 14, 2022. [PDF] https://www.wpath.org/media/cms/Documents/Public%20Policies/2022/USPATHWPATH%20Statement%20re%20Nov%2014%202022%20NYT%20Article%20Nov%2022%202022%20CORRECTION.pdf

GLAAD (February 14, 2023). 180+ journalists, New York Times contributors call out biased coverage of transgender people in joint letter as 100+ organizations and notables echo call, citing pattern of inaccurate, harmful trans coverage in the New York Times https://glaad.org/releases/new-york-times-contributors-call-out-biased-coverage-of-transgender-people-in-joint-letter/

2022 NYT story links

  • The Mental Health of Transgender Youth: Advances in Understanding Maureen D. Connolly, M.D. î„ź  ‱ Marcus J. Zervos, M.D. ‱ Charles J. Barone II, M.D. ‱ Christine C. Johnson, Ph.D. ‱ Christine L.M. Joseph, Ph.D. Published:August 18, 2016‱DOI:https://doi.org/10.1016/j.jadohealth.2016.06.012‱
  • Jody L. Herman Senior Scholar of Public Policy Andrew R. Flores Affiliated Scholar Kathryn K. O’Neill Policy Analyst How Many Adults and Youth Identify as Transgender in the United States? June 2022 https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/
  • Cass Review Interim report: Independent Review of Gender Identity Services for Children and Young People -https://cass.independent-review.uk/publications/interim-report/
  • Public consultation Interim service specification for specialist gender dysphoria services for children and young people 20 October 2022 -https://www.engage.england.nhs.uk/specialised-commissioning/gender-dysphoria-services/supporting_documents/B1937iiInterimservicespecificationforspecialistgenderdysphoriaservicesforchildrenandyoungpeople22.pdf
  • Emily Bazelon https://www.nytimes.com/2022/06/15/magazine/gender-therapy.html
  • Azeen Ghorayshi https://www.nytimes.com/2022/11/04/health/florida-gender-care-minors-medical-board.html
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6647755/
  • Johanna Olson-Kennedy, MD,corresponding author1 Yee-Ming Chan, MD, PhD,2 Robert Garofalo, MPH, MD,3 Norman Spack, MD,2 Diane Chen, PhD,4 Leslie Clark, PhD,1 Diane Ehrensaft, PhD,5 Marco Hidalgo, PhD,1 Amy Tishelman, PhD,2 and Stephen Rosenthal, MD5 Impact of Early Medical Treatment for Transgender Youth: Protocol for the Longitudinal, Observational Trans Youth Care Study JMIR Res Protoc. 2019 Jul; 8(7): e14434. Monitoring Editor: Gunther Eysenbach; Reviewed by James Lykens and Adrienne Pichon. doi: 10.2196/14434
  • CHAD TERHUNE, ROBIN RESPAUT, and MICHELLE CONLIN (Oct. 6, 2022). https://www.reuters.com/investigates/special-report/usa-transyouth-care/
  • Dani Blum (July 18, 2022). -https://www.nytimes.com/2022/07/18/well/live/endometriosis-symptoms-treatment.html
  • Putting numbers on the rise in children seeking gender care By ROBIN RESPAUT and CHAD TERHUNE Filed Oct. 6, 2022, https://www.reuters.com/investigates/special-report/usa-transyouth-data/
  • GORDON, CATHERINE M Skeletal Health and Bone Marrow Composition Among Youth Project Number 5R01HD101421-03 Contact PI/Project Leader .Other PIs Awardee Organization BOSTON CHILDREN’S HOSPITAL https://reporter.nih.gov/search/VccdwST9P0yW2AM-BR598g/project-details/10401768
  • Uppdrag granskning Mission: Investigate: Trans children -https://www.svtplay.se/video/33358590/uppdrag-granskning/mission-investigate-trans-children-avsnitt-1?info=visa
  • ,Stephen M. Rosenthal, M.D. statement-https://int.nyt.com/data/documenttools/rosenthal-in-alabama-court-case/f616e90a9b4bfe2d/full.pdf
  • Rick Rojas https://www.nytimes.com/2022/05/14/us/alabama-transgender-law.html
  • Consensus Parameter: Research Methodologies to Evaluate Neurodevelopmental Effects of Pubertal Suppression in Transgender Youth Diane Chen, John F. Strang, Victoria D. Kolbuck, Stephen M. Rosenthal, Kim Wallen, Deborah P. Waber, Laurence Steinberg, Cheryl L. Sisk, Judith Ross, Tomas Paus, Sven C. Mueller, Margaret M. McCarthy, Paul E. Micevych, Carol L. Martin, Baudewijntje P.C. Kreukels, Lauren Kenworthy, 
 See all authors  Published Online:11 Dec 2020https://doi.org/10.1089/trgh.2020.0006
  • Consensus Parameter: Research Methodologies to Evaluate Neurodevelopmental Effects of Pubertal Suppression in Transgender Youth Diane Chen, John F. Strang, Victoria D. Kolbuck, Stephen M. Rosenthal, Kim Wallen, Deborah P. Waber, Laurence Steinberg, Cheryl L. Sisk, Judith Ross, Tomas Paus, Sven C. Mueller, Margaret M. McCarthy, Paul E. Micevych, Carol L. Martin, Baudewijntje P.C. Kreukels, Lauren Kenworthy, Megan M. Herting, Agneta Herlitz, Ira R.J. Hebold Haraldsen, Ronald Dahl, Eveline A. Crone, Gordon J. Chelune, Sarah M. Burke, Sheri A. Berenbaum, Adriene M. Beltz, Julie Bakker, Lise Eliot, Eric Vilain, Gregory L. Wallace, Eric E. Nelson, and Robert Garofalo-https://www.liebertpub.com/doi/10.1089/trgh.2020.0006
  • http://admin.endocrine.org/news-and-advocacy/news-room/2022/longer-treatment-with-puberty-delaying-medication-leads-to-lower-bone-mineral-density -https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9624627/
  • “Bone Mass in Young Adulthood Following Gonadotropin-Releasing Hormone Analog Treatment and Cross-Sex Hormone Treatment in Adolescents With Gender Dysphoria,” Klink et. al, Journal of Clinical Endocrinology & Metabolism, 2015
  • “Effect of Pubertal Suppression and Cross-Sex Hormone Therapy on Bone Turnover Markers and Bone Mineral Apparent Density (BMAD) in Transgender Adolescents,” Vlot et. al, Bone, 2017 
  • “The Effect of GnRH Analogue Treatment on Bone Mineral Density in Young Adolescents With Gender Dysphoria: Findings From a Large National Cohort,” Joseph et. al, Journal of Pediatric Endocrinology and Metabolism, 2019
  • “Physical Changes, Laboratory Parameters and Bone Mineral Density During Testosterone Treatment in Adolescents With Gender Dysphoria,” Stoffers et. al, The Journal of Sexual Medicine, 2019
  • “Bone Development in Transgender Adolescents Treated With GnRH Analogues and Subsequent Gender-Affirming Hormones,” Schagen et. al, Journal of Clinical Endocrinology & Metabolism, 2020
  • “Short-Term Outcomes of Pubertal Suppression in a Selected Cohort of 12- to 15-Year-Old Young People With Persistent Gender Dysphoria in the U.K.,” Carmichael et. al, PLOS One, 2021
  • “Pubertal Suppression, Bone Mass and Body Composition in Youth With Gender Dysphoria,” Navabi et. al, Pediatrics, 2021