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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.
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.
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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