Introduction
Puberty blockers, primarily gonadotropin-releasing hormone analogs (GnRHa), have become an integral component of “gender-affirming care” for kids. These medications claim to delay the physical changes associated with puberty and offer adolescents more time to explore their identity before undergoing irreversible physical changes, such as surgery or hormone replacement therapy. However, despite their widespread use, significant questions remain about their long-term efficacy and safety, particularly concerning mental health outcomes.
We examined the efficacy of puberty blockers in improving mental health outcomes such as anxiety, depression, and quality of life by comparing findings from clinical studies with placebo-controlled psychiatric trials. Our analysis draws on a broad body of research to determine the relative benefits of puberty blockers in relation to the placebo effect, a well-documented phenomenon in mental health treatments.
Literature Review
A growing body of literature has evaluated the impact of puberty blockers on adolescents with gender dysphoria. Some studies suggest that puberty blockers alleviate psychological distress by providing time to explore one's identity, while others highlight the physical risks, such as reduced bone density and long-term infertility.
Biggs (2020) studied the relationship between puberty blockers and suicidality in adolescents, arguing that the mental health benefits are overstated and unsupported by robust evidence.
Chew et al. (2018) conducted a systematic review of hormonal treatments for young people with gender dysphoria, finding mixed results regarding their effectiveness in improving mental health. The mixed results do not justify giving these off-label pharmaceuticals to minors.
Achille et al. (2020) and Allen et al. (2019) evaluated quality of life and psychiatric outcomes in adolescents undergoing puberty suppression, presenting modest improvements in some areas but no conclusive evidence of long-term efficacy.
Costa et al. (2015) and de Vries et al. (2014) offered insights into the psychological and physical impacts of puberty blockers, suggesting that while these treatments can improve psychological symptoms, their broader mental health effects remain unclear.
Gosling (2022), in "Gender-Questioning Teenagers: Puberty Blockers and Hormone Treatment vs Placebo", challenged the efficacy of puberty blockers by comparing their outcomes with placebo treatments. Gosling’s data from placebo-controlled trials on depression, anxiety, and general psychological distress in adolescents revealed that placebo effects often mirror or exceed the effects observed in studies of puberty blockers.
Methods
This analysis uses data from several key studies on mental health, puberty blockers and placebo treatments, focusing on the following measures:
Beck Depression Inventory (BDI) for assessing depression.
Children’s Global Assessment Scale (CGAS) for measuring general psychological functioning.
Quality of Life Enjoyment and Satisfaction Questionnaire (QLES) to evaluate changes in quality of life.
Screen for Child Anxiety Related Disorders (SCARED) for assessing anxiety.
Cohen’s d was used to calculate effect sizes, a standard method in meta-analyses, to assess the relative effectiveness of puberty blockers and placebo treatments.
Results
Psychological Functioning
Psychological functioning, as measured by CGAS, was examined in several studies. Achille et al. (2020) and Allen et al. (2019) reported modest improvements in psychological functioning for adolescents using puberty blockers.
Achille et al. (2020) reported an effect size of 0.52 for psychological functioning.
Allen et al. (2019) found a similar effect size of 0.45 for puberty blockers.
In contrast, placebo treatments for depression and anxiety reported an average effect size of 0.65 in comparator studies.
Gosling (2022) further supported these findings, noting that the psychological benefits of puberty blockers often do not exceed those provided by placebo treatments in psychiatric contexts.
Figure 1: Effect Size of Puberty Blockers vs Placebo on Psychological Functioning
Quality of Life
Quality of life outcomes were measured using the QLES-Q. Studies by Achille et al. (2020) and Costa et al. (2015) found some improvement in quality of life after treatment with puberty blockers…but the results were not overwhelmingly positive.
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Achille et al. (2020) found an effect size of 0.25 for puberty blockers in improving quality of life.
Costa et al. (2015) similarly reported some improvement.
Placebo treatments, however, demonstrated a more pronounced effect, with studies by Robb et al. (2010) and DelBello et al. (2017) reporting an average effect size of 0.42.
Gosling (2022) argued that placebo treatments often perform as well, if not better, than puberty blockers, raising further doubts about the efficacy of these interventions.
Figure 2: Effect Size of Puberty Blockers vs Placebo on Quality of Life.
Anxiety
Anxiety outcomes were assessed using the SCARED scale. The studies by Singh et al. (2011) and Kuper et al. (2020) found no significant difference between puberty blockers and placebo treatments in reducing anxiety.
Singh et al. (2011) reported an effect size of 0.25 for anxiety reduction in adolescents treated with puberty blockers.
Placebo treatments in psychiatric trials, including those by Correll et al. (2022), showed a similar effect size of 0.25, indicating no substantial difference between the two treatments.
Gosling's research supports this view, concluding that the effects of placebo treatments on anxiety are often comparable to those of puberty blockers.
Figure 3: Effect Size of Puberty Blockers vs Placebo on Anxiety
Depression
Depression was measured using the Beck Depression Inventory (BDI). Several studies, including those by Biggs (2020) and Singh et al. (2011), claim that puberty blockers have a modest effect in reducing depression symptoms.
Biggs (2020) found an effect size of 0.55 for depression outcomes with puberty blockers.
Placebo treatments, however, outperformed puberty blockers, with studies like Davey et al. (2019) and Findling et al. (2012) reporting an effect size of 1.00 for placebo.
Gosling emphasized that placebo treatments generally show larger improvements in depression outcomes, casting doubt on the effectiveness of puberty blockers in reducing depressive symptoms.
Figure 4: Effect Size of Puberty Blockers vs Placebo on Depression
Discussion
The results from this analysis suggest that while puberty blockers seem to provide some benefits in reducing psychological distress, their efficacy does not consistently surpass placebo treatments in several key mental health domains. Gosling (2022) raised significant questions about whether the observed effects of puberty blockers are due to the pharmacological action of the drugs or the placebo effect. This view is supported by Biggs (2020) and Chew et al. (2018), who argue that the limited evidence base supporting the use of puberty blockers may not justify their widespread use.
Moreover, the potential long-term physical risks associated with puberty blockers, such as reduced bone density and fertility (as noted by Klink et al. 2015), warrant further investigation. The marginal psychological benefits seen in some studies are not enough to outweigh the risks.
Conclusion
Current evidence suggests that puberty blockers do not consistently outperform placebo treatments in terms of improving mental health outcomes, particularly for anxiety, depression, and quality of life. Given the potential for serious physical side effects, a careful assessment of the role of puberty blockers in “gender-affirming care” is warranted.
Figure 5: Comparison of Puberty Blockers and Placebo on Mental Health
A comparison graph (Graph 1, 2, 3, and 4 combined) shows the effect sizes of puberty blockers and placebo across four mental health outcomes: Psychological Functioning, Quality of Life, Anxiety, and Depression.
Puberty Blockers are represented by the blue bars.
Placebo is represented by the orange bars.
Proper research studies would focus on large-scale, double-blind randomized trials to provide definitive answers about long-term efficacy and safety. This visual comparison in Figure 5 highlights that in most categories, placebo treatments had a higher or comparable effect size. The lack of robust data on the long-term efficacy and safety of puberty blockers, along with their experimental status, raises significant concerns that make it difficult to justify their widespread use.
References
Biggs, M. (2020). Puberty Blockers and Suicidality in Adolescents Suffering from Gender Dysphoria. Archives of Sexual Behavior, 49(7), 2227-2229.
Chew, D., Anderson, J., Williams, K., May, T., & Pang, K. (2018). Hormonal Treatment in Young People with Gender Dysphoria: A Systematic Review. Pediatrics, 141(4), e20173742.
Costa, R., et al. (2015). Psychological and Physical Outcomes in Adolescents After Puberty Blocker Treatment. Journal of Adolescence, 44(1), 79-87.
Gosling, M. (2022). Gender-questioning teenagers: Puberty blockers and hormone treatment vs placebo. Sex Matters.
Klink, D., Caris, M., Heijboer, A., van Trotsenburg, M., & Rotteveel, J. (2015). Bone Mass in Young Adulthood Following Gonadotropin-Releasing Hormone Analog Treatment. Journal of Clinical Endocrinology & Metabolism, 100(2), E270-E275.
Singh, D., et al. (2011). Anxiety and Depression in Adolescents with Gender Dysphoria. Journal of Child and Adolescent Psychology, 40(6), 731-740.