By Mikael Landén, Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
Puberty stands as a pivotal milestone in human development. Marking the transition from childhood to adolescence and beyond involves a complex interplay of biological, psychological and social changes. Puberty can be halted using gonadotropin-releasing hormone agonists (GnRHa) commonly referred to as ‘puberty blockers’. Their prescription rates have seen a notable increase in response to the rising incidence of gender dysphoria in adolescents, predominantly girls, in many Western countries. The rationale for suppressing puberty in these children is threefold: First to afford time for the child to reflect on their gender identity. Second, to alleviate gender dysphoria and prevent the worsening assumed to occur during puberty. And third, to forestall irreversible bodily changes that could complicate a subsequent transition to the opposite sex. The downsides of using GnRHa have been deemed small as the effects are reversible, with puberty resuming upon discontinuing the medication.
However, these tenets have recently come under scrutiny. First, one study revealed that 98% of 720 children who started GnRH treatment progressed to using cross-sex hormone therapy in adulthood.1 This finding challenges the notion that GnRHa treatment provides time for introspection and suggests instead that it serves as an initial step in the transition to the opposite sex. Second, a systematic review of ours, published in this journal, concluded that the evidence supporting the use of GnRHa to mitigate gender dysphoria and improve psychosocial functioning is insufficient.2 On the risk side, treatment with GnRH agonists impacts bone health by delaying the natural increase in bone mineral density that typically occurs during puberty. These conclusions echo those of independent reviews conducted by the National Institute for Health and Care Excellence (NICE) in England.3
Along with physiological processes, puberty heralds a critical neurodevelopmental window leading to changes in cognitive and behavioural functions that have enduring implications throughout life. It is therefore an important question whether disrupting the natural course of puberty through pharmacological intervention has neurodevelopmental implications. In our systematic review, we found only one, inconclusive, study on cognition in children with gender dysphoria receiving GnRHa therapy.4 Therefore, the further exploration of this issue by Dr Baxendale in the current issue of the journal is of considerable value.5
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