Arkansas has become the first state to ban gender-affirming care for minors, including the use of puberty blockers and hormone therapy, after the state legislature overrode Gov. Asa Hutchinson's veto of the bill.
The bill, which passed the state's House and Senate with a wide majority, bans doctors from providing any form of gender-affirming health care to people under the age of 18. Similar measures are being considered in Alabama, North Carolina and Tennessee, and more than 20 states are considering other restrictions on transgender children, even as transgender representation increases in legislatures.
Doctors have criticized the measure, especially its restriction on puberty blockers, which are used for multiple conditions beyond treating transgender children and are reversible.
What are puberty blockers?
Puberty-blocking medications are gonadotropin-releasing hormone agonists, which prevent the release of sex hormones, said Dr. Caroline Salas-Humara, a pediatrician at NYU Langone.
"What (puberty blockers) do is act at the level of the brain to basically change the way that the brain speaks to the glands to release sex hormones like estrogen or testosterone," Salas-Humara explained. "They effectively shut down the body's production of estrogen or testosterone."
Dr. Joshua Safer, an endocrinologist and the executive director of the Mount Sinai Center for Transgender Medicine and Surgery, emphasized that puberty blockers work "in a reversible fashion."
"What that means, relevant to kids entering puberty, is that you could basically revert to that just prior to pubertal state, and you could be maintained in that position," Safer said.
Puberty blockers can be administered in two fashions: Through injection, which will usually be done every one to three months, or via an implant in the upper arm, similar to some methods of birth control.
When are puberty blockers used?
Puberty-blocking medications are primarily used in young children who start puberty too early, according to Salas-Humara and Safer. The condition, known as precocious puberty, is diagnosed when girls before the age of 8 and boys before the age of 9 start to undergo puberty.
"The big historical using prior to using them for transgender care was precocious puberty," said Safer. "The idea is to have (kids) stay in their prepubescent state until they're a little bit older, a little bit more mature, and more around the age where others around them also might be going into puberty. That will work out better for them from a personal and social perspective."
Puberty blockers may also be used to treat prostate cancer in older men, according to Safer, and to manipulate hormones for women who are struggling with infertility. Most recently, puberty blockers have garnered some attention for their use in transgender children. Safer described this use as a "variation on the theme of precocious puberty."
"Kids will come and say they're transgender or they think they're transgender ... but they're entering puberty, and so it would be good to not have them go into the quote-unquote 'wrong' puberty, where they would have permanent characteristics that might have to be dealt with from a surgical perspective later," said Safer. "They're at a relatively young age, where it might be relatively early in the conversations ... to be making decisions with regard to more permanent things, but the physical changes are happening already, so it's an opportunity to pause that."
Salas-Humara and Safer both said that in these cases, doctors will use a multidisciplinary approach to make sure that puberty blockers are the best option for the child. Major medical organizations, including the American Academy of Pediatrics (AAP) and the Endocrine Society have both affirmed this diagnostic process.
"It's not just me as a medical provider deciding 'You know what, you're good to go,'" Salas-Humara explained. "We follow guidelines. The young person likely has seen a mental health provider who has expertise in gender identity ... There's oftentimes a social worker ... I certainly work with the parents, the parents need to be on board. It very much is a collaborative, multidisciplinary approach to care, rooted in science and data."
What are the benefits of puberty blockers?
Experts stress that more than 30 years of research into puberty blockers shows that the medication is safe, reversible and can be used to treat children without long-lasting effects. While most of the research on puberty blockers is in cisgender children, Safer said there is "no reason" to think that there would be different effects in transgender children.
The pause in puberty is the largest benefit of the medication. Dr. Samantha Busa, a psychologist and clinical director of the gender and sexuality service at the Child Study Center at Hassenfeld Children’s Hospital at NYU Langone, said that this comes with major benefits.
"(Puberty blockers allow) transgender kids to really be able to navigate situations without worrying about what their body looks like as soon as puberty becomes part of the picture," said Busa, noting concerns like the development of secondary sex characteristics. "... Blockers are a great way to help not have those characteristics develop, which could be really distressing to a transgender child, and on top of that, for kids who are still exploring their identity and feeling distress around puberty, blockers are a really great way to pause that development and allow for continued exploration."
Busa said that this ability to "pause" puberty can lead to a decrease in "psychological distress," which can be linked to lower rates of anxiety, depression and attempted suicide.
"We do know that blockers are associated with a decrease in suicide, and we also know that the blockers are associated with a reduction of depression as well," Salas-Humara said. "I definitely see clinical practice patients who come in and they're extremely anxious and depressed about the possibly of facial hair or breast development, and then we start the blocker and they're relieved. It's a weight off them. They have less depression, less anxiety, they're just able to function and be themselves in an authentic way."
What are the downsides of puberty blockers?
Safer said that research shows that the largest issue with the continued use of puberty blockers is that you need sex hormones, which are paused by the blockers, to maintain bone health.
"We know from kids with precocious puberty that if you give puberty blockers for a year or so, they end up pretty much in the same place, from a bone health perspective," Safer said. "That seems quite safe."
While Safer said he might be "nervous" to leave a child on a puberty blocker for an "extended period of time," that is not the normal prescription process for blockers: Usually they are used for a year or two at a time. Once that time is up, children will either start undergoing hormone therapy or go off the puberty blockers.
"Puberty blockers are very reversible," said Safer. "If you stop taking them, your normal, existing natural hormone processes come back."
How will this legislation affect transgender children?
"We know that transgender people who have been denied care have an increased likelihood of dying by suicide and engaging in self-harm," Salas-Humara said. "As a physician, any time I practice medicine I think 'Do no harm.' I think not allowing these young people to have access to puberty-blocking medications could potentially be harmful. There is harm inherent in denying these patients that medical therapy that has been demonstrated to be helpful and have positive effects."
Safer said that he would also be concerned that the legislation might limit access to puberty blockers for cisgender children going through precocious puberty or other conditions that might be treated with blockers or hormone therapy.
"Whenever the government tries to weigh in and tries to make a rule about health care delivery, it makes me nervous," Safer said. "We mostly leave these kinds of decisions to patients and their doctors and their parents because we customize treatments to individual circumstances in so many ways."
Busa said that the legislation may lead to more stress and anxiety among transgender children and others in the LGBTQ+ community.
"We're seeing kids really worried about their own care even if these things aren't related to them," Busa said. "They're hearing negative things about trans youth, which puts them at higher risk for feelings of anxiety, depression, feeling that their identity or existence isn't valid. ... It's not as simple as just rhetoric, it's making an impact on kids' day-to-day lives."