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Is there a doctor in the house? How about a structural engineer? Someone who hasn't slept through their statics class like I did?
Like I said I'm doing a deep dive into puberty blockers, since no one recommended anything better, I've stuck to that Science-Based Medicine article. I've been fixating on a single paragraph that I've been picking up, dropping, and picking up again:
The link leads to a paper titled "Development of Hip Bone Geometry During Gender‐Affirming Hormone Therapy in Transgender Adolescents Resembles That of the Experienced Gender When Pubertal Suspension Is Started in Early Puberty" (peer reviews available here). It's a retrospective study going through the data of the Amsterdam Cohort of Gender Dysphoria to find out if puberty blockers have an impact on the bone geometry (specifically on subperiosteal width, and endocortical diameter). It's a handy dataset, since, like the UK, until recently the Netherlands had only a single gender dysphoria clinic for the entire country, so anyone who wanted to transition had to go through them, so you don't have to worry about weird selection effects too much, and they tended run a bunch of tests on their patients, including dual‐energy X‐ray absorptiometry (DXA) scans, so the data is right there waiting to be analyzed.
When it comes to the results and the conclusion, I'm left squinting at what am I supposed to even be seeing here. The authors say they are looking at changes in bone geometry rather than the absolute levels, and a lot of the times the differences in changes between cis-men and cis-women aren't even noticable, so you can fit the trans population into either curve, or the changes for the trans population are so whack, that you can't fit them into either. The total amount of participants is pretty big, but by the time you split them into age/gender groups it ends up pretty small for each, and the values for the reference cis groups have a pretty big variance (and come from Sweden rather than the Netherlands, but I'll allow it), so I wonder if the whole exercise isn't a bit futile.
On the other hand an effect that seems to be staring me in the face is the effect on height. For both trans men and trans women, the earlier puberty blocking started, the taller the group seems to be. I always assumed blockers will make you shorter, since even gender clinics nowadays admit an impact on growth spurts. I expected it would follow the simple logic of: growth spurts happen during puberty -> but puberty is blocked -> therefore you'll end up shorter than otherwise. It turns out we have something called growth plates which close at the end of puberty and lock in our bone size. Puberty blockers prevent that process, which gives the bones some extra time to grow. It may well be that blockers still have a negative impact on growth spurts, but it's compensated by the delay in closing the growth plates.
On the gripping hand, I'm not sure about the conclusion. Eyeballing the average heights, the patients seem somewhat shorter than the average Dutch I remember seeing on the streets of Amsterdam, and there are also studies saying blockers have no, or a slightly negative effect on growth, so maybe we haven't completely escaped weird selection effects. There are also anecdotes, and statements from other gender clinics, so I'm getting the impression that we don't know either way.
Anyway, this is where statics come in. If it is true that blockers make you taller, my long experience in bending and breaking sticks tells me that other things being equal, a bone of a taller person will be easier to break. The paper concedes that blockers lower bone density, so it would seem it negatively impacts 2 factors responsible for bone health. Does that make sense to anyone else?
The annoying thing is that they used software for bone analysis that does a lot more than measure subperiosteal width and endocortical diameter. One of the papers they cited used the software to predict (with not horrible accuracy) the force a bone could withstand, and I have no idea why they didn't publish every parameter it could spit out. Their reason seems to be that they didn't have reference values to compare it to, but... so what? Just compare the values between different age groups. And while you're at it also add participants who never used blockers, and who never moved on to hormones which you specifically excluded.
That's it for now. No conclusion yet, just wanted a sanity check.
Castrati were famously very tall back in the day, for a comparable group of individuals
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If you’re talking about statistics, I have bad news regarding doctors…
Statics not statistics, I don't expect doctors to have a good understanding of it.
I confess I didn’t read the entirety of your comment at first and only skimmed the top, before you got to the classical mechanics part.
That said, I would expect non-orthopods to have an even worse understanding of statics than statistics, yes!
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Sure, this passes the sanity check.
Really though, I want to step back from that for just a moment and focus on just how disingenuous I believe the puberty blocker discourse to be from trans advocates. Without linking to outside drama, there were two threads in my local subreddits yesterday regarding how puberty blockers are "completely reversible", that they're validated by medical science, and have been long-used. Here's one example:
This is bullshit, and not in a fashion that implies misunderstanding, but the product of absolutely ridiculous lies that anyone with a thin grasp of developmental biology can spot in a moment. There is almost zero chance that you can just press pause on an important developmental process for years at a time and have it be "completely reversible". Perhaps after rigorous study we can settle on the position that it's the least-bad option available, but passing it off as totally harmless, so harmless that it could be used as on someone that just wanted attention is the product of bold-faced lying by people that are ostensibly medical professionals and scientists. That the default position on this has been flipped to it being requisite that you spend a great deal of time dealing with bone structure or any other singular dimension is privileging the null hypothesis despite the blatant, obvious reality that puberty has massive effects and that delaying it while other growth and aging processes continue will almost certainly have impacts on development. Again, maybe those won't be so bad, maybe on net it turns out to be an improvement for the kids, but I absolutely refuse to treat these as no big deal to pass out like candy.
I believe you can induce puberty medically in adults who never went through it because of birth defects and medical syndromes, though?
Ofc ‘completely reversible’ is an obvious tall tale and that leaves out all the other side effects. And of course you can’t undo going on cross sex hormones.
Yeah, delayed puberty as a category has long been believed to have only small impact on height and bone density. It's not clear how true that was -- constitutional delayed puberty does seem to correlate with a difference in height, it's just a question how much of that from the puberty itself as from family history... but the family history often includes delayed puberty -- and puberty blockers have further ramifications that could have results not present in conventional delayed puberty (although the only good evidence I've seen is from much larger doses than used for blocking puberty in trans kids).
That isn't to say that it's obviously true, or even likely true, but it's not self-evidently wrong from any knowledge of the topic.
That said, I think bone density is a pretty big distraction from the underlying questions: we're not having knock-down drag out fights over bad federal school milk policy, even though that impacts more students and probably manages to be even dumber. The soc con objection is that children on puberty blockers are far more likely to continue to identify as trans into adulthood, which there's pretty strong evidence in favor of, and, more controversially, that people who were on puberty blockers pre-transition may have long-term sexual issues in either their birth-assigned or transitioned genders into adulthood. These are going to have entirely unrelated answers.
Well yes. My objection to puberty blockers is more ‘being trans is a near-postulate bad thing, both for the individual and for broader society, and so we should be very concerned not to encourage it even if there’s legitimate debate about whether to treat individuals with white kid gloves’. I mean I agree that puberty blockers aren’t completely reversible and that long term side effects are part of the discussion, they just don’t seem like a generally important part.
Interestingly, I believe one of the common ‘anti-trans laws’ passed this year was for any insurance company which covered puberty blockers to pay for de transition costs, which would seem like it’s going to increase the data available to us on this question forthwith.
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This sort of argument really bothers me, it's reminiscent of lefties trying to tell me the culture war is a distraction, and we should focus on the economy or workers rights. We don't have knock-down drag out fights about school milk policy because, to my knowledge, no one is trying to say malnutrition is fully reversible. Also, I can just buy milk for my kids.
If people don't think the impact on bone health is a big deal, just list it as one of the possible effects, explain why you think it's not important, and move on. Don't gaslight parents into thinking there's no permanent changes, and immediately flip to "well, ok, but that one's not so important" as soon as someone points to a permanent change.
Funnily enough I'm somehow skeptical of that one. I did hear a plausible mechanism for how it could happen (puberty being one of the things that resolves dysphoria for a lot of kids), but somehow my first thought on it is that's it's just the sunk cost fallacy, rather than something inherent to blockers.
Yeah, that's fair, and there's certainly some people who make the position dishonestly. I do think there's at least some who had people skeptical of puberty blockers bring the matter up, went by either a gut check or relayed information, and then had that response to further concerns, rather than going to full "it's happening and it's good".
Ehh.... federal policy has strictly limited the types available for sale or purchase in schools (that accept federal funds, or are in New York) to types that are less palatable to most people.
I think there's a lot of reasons to contest the proposed methodology, and the available data is so small and so time- and space-sensitive that it's definitely not strong evidence in any direction, so that's fair.
I meant buy whatever I want in a store, and put it in my kid's lunchbox. That's still legal.... right?
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The actual mechanism is kind of irrelevant, no? I mean the objection is ‘we should encourage desistance’. Why puberty blockers run contrary to that doesn’t matter.
At least some mechanisms are 'portable'; for something like sunk costs, one could easily invest in social transition, clothing, make-up, moving to a pro-trans location, so on, without having access to pharmaceutical or surgical transition.
That’s true, but some of the suppressing effect on trans from banning puberty blockers is probably also portable.
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You might replicate a number of hormonal processes but it's hard to believe a developmental process could be so malleable, especially brain development. We actually don't even know very well what changes puberty induces in the brain.
If you have had a child you will see that evolution gives us a development cycle that is as rapid as possible factoring in the complexity to get us to adulthood as physically developed, socially competent adults. This involves various critical periods that it seems unlikely allow for years long pausing. Not to mention becoming out of sync with our peer group, which is how our identity is shaped.
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Honestly it’s because of the narrative. They simply cannot admit or allow others to admit that transition is anything but good. Any decision you make has trade offs. That’s just life. Even social transition has trade offs (mostly in creating a social rejection by the natal sex peers. Kids tend to pair off by gender and while there might be exceptions, for the most part, a girl who’s too masculine will be rejected by girls and thus never get any path toward acceptance by girls. Boys do the same. Thus you create a situation where de-social-transition means rejection of their peer group and no acceptance by the other sex, and thus loneliness.).
It’s always come off as a weird cultish sales pitch. Everything must be wonderful and anyone who says otherwise is sowing FUD and driving kids to suicide. No decision is that way. Choosing something means making a trade off. Choosing a major in college is a trade off. Eating Pizza instead of spaghetti is a trade off.
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Puberty blockers have been used to date on children undergoing puberty at way too young an age. There's a difference between "six year old girl is going through puberty, let's halt it until she's nine or so and let her undergo natural puberty" and "let's stop twelve year old girl from undergoing natural puberty for an undefined period and put her on track to switching over to taking cross-sex hormones".
Even for the children with early puberty, my understanding is that there are health risks, but the gain outweighs the risk in that case. We don't have enough long-term evidence of ordinary children with normal puberty having that halted, but it's the activists who want to sell it as "perfectly harmless, perfectly reversible" and they are the ones putting pressure on the medical services, who in many cases are all too willing to go along (either from fear of being sued by the activists in a case like this or because key decision makers have drunk the Kool-aid).
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Yeah, I can cut the average local subredditor some slack, but there are actual, practicing, doctors of medicine saying this stuff, and that's where I lose my mind. After reading some amount of literature on it, I can even tell you what logic they use to justify the claim, and it's simply: if you stop taking blockers, their effect on hormones will cease, you will no longer be blocked. Of course by that criterion I struggle to think of a drug that's not "fully reversible". Even the chokehold on Jordan Neely was "fully reversible" if that's how you want to look at it.
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This passes the sanity check for me.
Simplified version: think of puberty as a trigger in the opposite direction from what you’re thinking. It’s a process that tells the body: “hey, we’re finishing up the growing portion of life.”
Other posters mentioned eunuchs. Not that many eunuchs around these days so data is scarce, but we do have a mammalian population we can draw insight from: dogs.
The consensus is that neutering dogs does lead to an increased size.
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In fifth grade in my biology textbook (early 90s) it was mentioned that eunuchs grew quite tall but feminine. If you view puberty blockers as somewhat less extreme and temporarily version of castration that is absolutely not surprising.
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Interesting; that sounds like what is recorded of the castrati:
"As the castrato's body grew, his lack of testosterone meant that his epiphyses (bone-joints) did not harden in the normal manner. Thus the limbs of the castrati often grew unusually long, as did their ribs. This, combined with intensive training, gave them unrivalled lung-power and breath capacity. Operating through small, child-sized vocal cords, their voices were also extraordinarily flexible, and quite different from the equivalent adult female voice. Their vocal range was higher than that of the uncastrated adult male."
Height can be via long torso or long limbs, if the puberty blocking acts like the castrati and limb growth proceeds then they may indeed be taller. We'll have to presume that a similar mechanism operates for girls on puberty blockers since we have no historical parallel with which to compare them.
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