Remember Bone Density Concerns? Study Finds Few Long-Term Issues One Year After NYT Article

Last November, the New York Times devoted thousands of words to concerns that puberty blockers might cause lifelong problems with skeletal health. A new study validates critics who suggested these concerns were overblown.

One year ago, give or take a few days, the New York Times published a lengthy feature suggesting there might be a cost to trans youth who used puberty blockers to delay the unwanted changes of endogenous puberty. The NYT’s focus was on bone density, and they quoted multiple experts expressing concerns that when youth delay puberty, which also delays expected gains in bone density, the impacts would be permanent. Many in the trans community were taken aback at the slanted, misleading frame to the story, which presented a fairly routine side effect as if it were a major scandal, myself included. Now, new research suggests the fears were wildly overblown, and there’s no reason for long term concerns about bone health for transmasculine youth taking puberty blockers.

In their story, the NYT downplayed the mainstream belief that bone density would rebound after patients proceeded to cross sex hormone treatments as they transitioned. Instead, it emphasized the concerns of a few researchers who believed there could be a long-term negative impact. More recently, a study in JAMA Pediatrics suggests that mainstream belief was largely correct, particularly for transmasculine patients. (For transfemmes there seem to be more valid concerns about long-term bone density.)

Given a climate of hyper-concern over the transitions of trans boys, specifically, it is welcome news that there seems not to be any reason to fear long-term harm to bone health post-transition. Unfortunately, the damage of the fearmongering NYT coverage has largely been done, with puberty blockers for trans youth having been banned in 20 states since that article.

Here’s an excerpt capturing the tone of the November 2022 story:

screenshot from the New York Times

The prediction by Dr. Khosla now seems much less plausible. Dr. Marianne van der Loos and her co-writers reported, in a recent study for JAMA Pediatrics, “In individuals assigned female at birth, BMD z scores caught up with pretreatment levels at the lumbar spine, total hip, and femoral neck.”

The study looked at patients who had been treated with cross-sex hormones for at least 9 years, a much longer period than previous studies. They found that, for trans men, bone density had returned to normal after that period. Results for trans women were somewhat more concerning. Bone density scores returned to normal in the hip and neck, but scores for the lumbar spine remained below what was expected. Taken together, this suggests that bone density issues are not a long-term concern for trans men and transmascs who follow puberty blockers with testosterone therapy (though bone density should be monitored for all patients while on puberty blockers), but that transfemme youth are at risk, and more efforts should be made to ensure their bones are healthy. (The study notes it is not clear if ongoing bone density issues for transfemmes are related to puberty blockers themselves, or to transfemme hormone treatments.)

This is a very different picture from the one presented in the NYT article, which focused primarily on risks to patients who were assigned female. The NYT story featured three patients who had taken puberty blockers, one a female detransitioner, one a female-assigned youth whose parents had stopped all gender-affirming treatment after becoming aware of bone density issues, and one a transfemme youth with no reported bone density problems.

This choice of patients followed a trend in the NYT and other outlets of raising particular concerns about transmasculine youth. However, it did not align with the evidence of who was at the most risk at the time of publication. As the NYT story briefly mentioned, studies that had been conducted by the time showed trans men on testosterone had bone density scores approaching normal after a few years, while trans women’s scores lagged. Multiple quotes in the story failed to make that distinction, and instead predicted permanent issues for all youth. The particular families highlighted seemed to further underscore a particular worry over female-assigned children and downplay the likelihood that testosterone therapy would help trans boys regain their bone density.

screenshot from the New York Times

The confusion over who has the most to worry about when it comes to bone health could perhaps be resolved by cisgender people having a less rigid view of sex differences (and less transmisogyny). It makes sense that transfemmes are at a greater risk, because bone density issues are more prevalent in women. The National Institute on Aging’s information on the most severe version bone disease, called osteoporosis, highlights this fact, saying “Osteoporosis affects about one in five women over age 50, but only one in 20 men.”

By viewing trans people through the lens of a “biological sex” members of the mainstream, including reporters, may be poorly prepared for the reality that trans men’s health risks tend to be similar to that of cis men, with particular concerns around heart disease, while the issues impacting trans women are more comparable to those of cis women, including bone density issues. (It is unclear from the study in JAMA Pediatrics how the bone density of the trans men and women studied compared to cisgender members of the same gender.)

The damage done by the NYT’s story on puberty blockers is hard to overstate. In November 2022, when the piece was published, only two states had passed a total ban on gender-affirming care. 2023 saw an onslaught of such legislation, with 19 additional states passing care bans, many of which cited the NYT reporting (in this and other stories) as part of their reasoning.

While it’s wonderful news that puberty blockers are likely not to cause long-term issues with bone density for transmasculine youth, the likelihood that they can cause such issues for transfemmes doesn’t mean the benefits aren’t worth the risks to them. Instead, as with all medical decisions, the risks and benefits should be laid out for the patients and their families, and a decision made based on individual factors such as the severity of a child’s gender dysphoria, their current bone density, and any other relevant physical and mental health issues. In this, gender-affirming care should function like other medical treatments, where the risk of side effects are considered seriously, but not a reason to fear commencing treatment when necessary.