Puberty Blockers, Cross-Sex Hormones, and Youth Suicide

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Lowering legal barriers to make it easier for minors to undergo cross-sex medical interventions without parental consent does not reduce suicide rates—in fact, it likely leads to higher rates of suicide among young people in states that adopt these changes. States should instead adopt parental bills of rights that affirm the fact that parents have primary responsibility for their children’s education and health, and that require school officials and health professionals to receive permission from parents before administering health services, including medication and “gender-affirming” counseling, to children under 18. States should also tighten the criteria for receiving cross-sex treatments, including raising the minimum eligibility age.

Key Takeaways

  1. U.S. policymakers are seeking to make it easier for minors to access puberty blockers and cross-sex hormones based on the claim that doing so reduces suicide risk.
  2. Studies finding that “gender-affirming” interventions prevent suicide fail to show a causal relationship and have been poorly executed.
  3. A superior research design shows that easing access to puberty blockers and cross-sex hormones by minors without parental consent increases suicide rates.

Adolescents who are confused about their gender suffer from an abnormally high suicide rate. REF Though research demonstrates that gender confusion generally resolves itself without medical intervention, REF some educators and medical professionals encourage teens, and even pre-teens, to take puberty blockers or cross-sex hormones so that their secondary sex characteristics, such as body and facial hair, breast tissue, muscular build, and fat composition, align more closely with the gender with which they identify. REF While the World Professional Association for Transgender Health (WPATH) acknowledges that these interventions can have significant complications, it warns that delaying intervention also has serious risks:

Refusing timely medical interventions for adolescents might prolong gender dysphoria and contribute to an appearance that could provoke abuse and stigmatization. As the level of gender-related abuse is strongly associated with the degree of psychiatric distress during adolescence (Nuttbrock et al., 2010), withholding puberty suppression and subsequent feminizing or masculinizing hormone therapy is not a neutral option for adolescents. REF

Other advocates, members of the media, and even White House staff invoke scientific authority to assert that cross-sex medical interventions reduce the risk of suicide. Sarah Harte, director for the Washington, DC, branch of an organization that provides medical intervention and support for youth called The Dorm, stated with confidence that “[l]aws and systems barring gender-affirming healthcare will contribute to higher rates of significant mental health problems, including deaths by suicide.”REF The CEO of The Trevor Project, Amit Paley, said, “It’s clear that gender-affirming care has the potential to reduce rates of depression and suicide attempts.”REF

In an opinion piece in The Washington Post, University of Virginia Law School professors Anne Coughlin and Naomi Cahn claimed that cross-sex medication “has been shown to reduce the risk of depression and suicide for transgender youth,” and that “banning it creates an excruciating conflict for parents, as the steps they take to preserve their children’s lives may lead the state to investigate and punish them.”REF Even former White House press secretary Jen Psaki referred to such medical interventions as “medically necessary, lifesaving healthcare for [kids].”REF

The danger of adolescents committing suicide if they do not receive these medical interventions is thought to be so urgent that the Biden Administration recently issued a statement “confirming the positive impact of gender affirming care on youth mental health,” while referencing “the evidence behind the positive effects of gender affirming care.”REF A number of states have also considered or enacted legislation making it easier for minors to access cross-sex interventions without their parents’ knowledge or consent. For example, California recently enacted a new law, AB 1184, to prevent insurance companies from notifying parents if children on their policies receive “sensitive services,” which were defined to include “gender affirming care.”REF

However, young people may also experience significant and irreversible harms from such medical interventions.REF This Backgrounder reviews existing research on the relationship between cross-sex interventions and suicide, and then presents a new empirical analysis that examines whether easing access by adolescents to these interventions is likely to result in fewer adolescent suicides. The new analysis presented here finds that the existing literature on this topic suffers from a series of weaknesses that prevent researchers from being able to draw credible causal conclusions about a relationship between medical interventions and suicide. Using a superior research design, the new analysis finds that increasing minors’ access to cross-sex interventions is associated with a significant increase in the adolescent suicide rate. Rather than facilitating access by minors to these medical interventions without parental consent, states should be pursuing policies that strengthen parental involvement in these important decisions with life-long implications for their children.

The Context

Around 1990, some doctors in the Netherlands began to use drugs designed to delay the onset of puberty in teenagers who were confused about their gender.REF Puberty-blocking therapies, such as gonadotropin-releasing hormone analogues, were meant to prevent children entering puberty from developing the secondary sex characteristics, such as facial hair for men or breasts for women, if those features did not align with the gender with which they identified. Puberty blockers would be followed by the use of sex hormones, such as testosterone, for girls who identify as male, and estrogen for boys who identify as female, so that they could develop secondary sex characteristics that were associated with the sex that they identified with.REF

This treatment protocol of puberty blockers followed by cross-sex hormones among adolescents did not exist in the United States prior to 2007 and was extremely rare before 2010. Cross-sex hormones were available as a medical intervention for adolescents before 2010, but their use was extremely limited. Starting in 2010, however, the use of both puberty blockers and cross-sex hormones for adolescents who identified as transgender rose dramatically and was widely available by 2015.

Precise data are not available on how often puberty blockers and cross-sex hormones have been given to teenagers over time in the United States, but it is possible to track a proxy for these interventions. Google Trends provides data on the relative frequency that terms have been used for searches since 2004. A score of 100 in Google Trends indicates the peak frequency for the term. Before August 2007, Google Trends reports a 0 for the term “puberty blockers,” meaning that it was searched so infrequently in the U.S. that “there was not enough data for this term.” The term “puberty blockers” did not average 5, or one-twentieth of its peak popularity, in any year before 2015.REF

The average of the Google Trends scores for the terms, “puberty blockers,” “transgender,” “gender identity disorder,” and “gender dysphoria,” yields a reasonable proxy for how common cross-sex interventions have been over time.REF As shown in Chart 1, these four terms were searched infrequently until about 2015, when there was a dramatic increase that continued through the end of 2020. This picture is consistent with anecdotal reports of how the use of puberty blockers and cross-sex hormones only became widely available in the past several years.

By Jay Greene, Ph.D.

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