Pausing puberty for gender expansive youth: a conversation with Dr. Angela Kade Goepferd

Alex Iantaffi interviews Dr. Angela Kade Goepferd about puberty blockers, in light of the Bell V Tavistock decision in the UK. They discuss why this decision is relevant in the UK and beyond, what puberty blockers are (and what is puberty), as well as the reasons why this is such a safe and effective treatment for some trans, nonbinary, and/or gender expansive children and youth. Angela Kade Goepferd, MD (she/they), is the Chief Education Officer for Children’s Minnesota, Chief of Staff, pediatrician in the Children’s Minneapolis Primary Care clinic and medical director of Children’s Gender Health Program. 

Dr. Goepferd has a passion for working with underserved and at-risk kids and families, speaks Spanish and cares for a diverse community of patients in the primary care clinic. In addition to running the academic education and health professional education programs for Children’s, Dr. Goeperd is the Chief of the Professional Staff. They are a leader in the LGBTQ community who is driving equitable care for LGBTQ youth, particularly transgender and gender expansive youth and is a sought after speaker and trainer on these topics. They were a member of the LGBT Standards of Care Advisory board, which developed the first healthcare standards for LGBT people in the state of Minnesota,  and have been a recipient of one of the inaugural Business of Pride awards from the Minneapolis/St. Paul Business Journal in 2018, and winner of a special recognition award from the American Academy of Pediatrics in 2019 for advocacy and education about LGBTQ youth. In 2020 they gave their first TEDx talk, titled “The revolutionary truth about kids and gender identity” as part of TEDxMinneapolis. 

Transcript

Intro: 0:30

Everyone has a relationship with gender. What's your story? Hello, and welcome to Gender Stories with your host, Dr. Alex Iantaffi.

Alex Iantaffi: 0:38

Hello and welcome to the first episode of season four. I cannot believe that gender stories have been going on for so long. So thank you everybody, for listening and for keep the audience keeps growing. So thank you for recommending this podcast, to your friends and family. And today as ever, I am super excited because I always have the best guests. That's just how it is I'm sorry. But today I have Dr. Angela Kade Goepferd with me, and they are the chief education officer for Children's Minnesota. They're the Chief of Staff and the pediatrician in the children's Minneapolis primary care clinic and the medical director of Children's Gender Health Program. Dr. Goepfert has been with Children's for 15 years, and in that time, they've been an advocate for advancing equitable health care for all children that helped to create and cultivate the children's way values to ensure a positive experience for patients, families and professional staff. And they've been an engaged member and leader on several committees, strategic planning teams and other initiatives across the organization. Dr. Goepfert has a passion for working with underserved and at risk kids and families. They speak Spanish and care for a diverse community of patients in the primary care clinic that they're in. In addition, they also ran the academic education and health professional education programs for Children's and they're the chief of the professional staff. They're a leader in the LGBTQ community and they're driving equitable care for LGBTQ youth, particularly trans non binary and gender expansive youth. And they're a sought after speaker and trainer on this topic. So I'm really, really excited to be talking with them about puberty blockers today, the way a member of the LGBT standards of care advisory board that developed they helped develop the first healthcare standards for LGBT people in the state of Minnesota. And they're a recipient of one of the inaugural business of pride awards from the Minneapolis St. Paul Business Journal's in 2018. And we're winner of a special recognition award from the American Academy of Pediatrics in 2019 for advocacy and education about LGBTQ youth. In 2020, they gave their first TEDx talk titled The Revolutionary Truth About Kids and Gender Identity as part of TEDx Minneapolis. And don't worry, I'll put the link to that TEDx talk in the episode description there listeners so that you can find it and listen to more of the kids amazing work. So welcome on Gender Stories. Thank you so much for making the time to speak with me today. I know that you're incredibly busy. So I'm so grateful that you made time for this today.

Dr. Angela Goepferd: 3:24

Yeah, absolutely. Thanks for having me, Alex, I'm really happy to be here. So I'm really excited to be talking with you. And I've known you and community for a little while. So I know just how amazing the work that you've been doing is. But unfortunately, one of the things that brought us together today is this decision in the UK that people may or may not have heard about called the Bell versus Tavistock decision, which kind of encourage some providers to kind of write a response even though you are US based. And this happened in the UK. And that decision, really, if I understand correctly, as a non legal person means that it's going to be incredibly difficult, if not impossible, for youth in the UK, who are looking or seeking to get puberty blockers kind of based on gender identity issues to be able to access this treatment unless they're 18 years old. Is that your understanding as well of basically what the decision is? Unfortunately, that's my understanding as well. Yeah.

Alex Iantaffi: 4:28

So and this decision seems to be part of this much bigger kind of trans moral panic that's been going on in the UK for several years now. But this movement seems sadly to be growing. And I know that many of my friends and colleagues in the UK are kind of part of trans community have been really impacted by different waves of this kind of trans moral panic. And often of course, when it comes to gender, there's always a moment when people are like, what about the children? You know, our children are old enough to make those decisions you know, should anybody makes those terrible decisions about their body before their 18th? And so today that's, that's what we're here to talk about a the fact that, you know, people make decisions about their bodies all the time before they're 18 years old. But specifically, what are puberty blockers? So let's start from why is this decision relevant beyond the UK? So you are based here on the Anishinaabe lands in what is currently known as the United States? Why does this matter to you as a pediatrician here?

Dr. Angela Goepferd: 5:34

Well, I mean, first and foremost, it matters to me because I care about all kids, no matter where they live. And I think you know, all kids have the right to grow up to be happy and healthy and safe and strong. And so if there are kids who will never be patients of mine in the UK, that can't get the necessary medical care that they need, I care about it. So that's probably first and foremost. But I think, you know, earlier, you referenced this trans moral panic. And that's, that's not unique to the UK. We see that here in the United States, and we see it specifically around this issue. So there have been several, you know, proposed pieces of legislation across this country that are trying to restrict access to medical care for trans people, and specifically for trans children. So I have no pretense that what happens in the UK relative to this topic will stay in the UK, I think it's happening here in the United States, and it will only continue to happen. And those of us who advocate for trans and gender expansive kids need to be strong voices to make sure that we protect the health and really the right to health care for these kids.

Alex Iantaffi: 6:41

Absolutely. I believe that there's a bill kind of not that different from what has happened in the UK, kind of in Montana right now, trying to stop treatment of trans and gender expansive or non binary youth. And I agree this was far closer to home than, than we would like to think sometimes I think there are so many misconceptions about the treatment that youth can access. And so maybe we can start from there. Because I think sometimes people are so confused about what is happening and to whom on a medical level, right? And of course, I also really want to name that not all trans or non binary, gender expansive youth are necessarily all going to seek medical care. But when they do seek medical care, kind of what when is the first time that as a pediatrician, you would see like, trans youth or non binary youth for gender expansive child kind of in your practice, specifically for gender related treatment?

Dr. Angela Goepferd: 7:42

Yeah, that's a great question. And you're right, every, every trans or gender diverse kid is different. And so not all kids are going to need medical intervention of any kind. But many kids do need a doctor. And for that reason, I actually have seen kids, both in my primary care practice and in the gender health program, as young as three, four and five years old, to have conversations and really up until kids hit the age of puberty. There's no medical interventions that we offer for kids. And what we're doing in those situations is really helping parents and kids understand concepts of gender, we're helping parents understand how to best support their kids, how to best protect their kids in school settings, and other places where they may need some supportive resources around how they have these conversations with their teachers, with their grandparents, with other family members, with the neighbors down the street. So up until the age of puberty, we certainly see kids at the doctor's office. And what we're doing is providing supportive and affirming care, which is primarily conversations answering questions, helping access resources. So the first point that we would do any type of medical intervention would be the onset of puberty, which for most kids is going to be between the ages of nine and twelve. Somewhere in there.

Alex Iantaffi: 9:06

Yeah. And I think that this idea of puberty sometimes is really nebulous for people so how do you assess if a child is kind of hit puberty? Which I know gets more in the medical stuff, but I think that's important for people to... what are the changes they're looking for?

Dr. Angela Goepferd: 9:22

It's that's, it's I think, when I talked to families in clinic, that's where I start is what is puberty? What are we talking about when we talk about puberty? And you know, when I say to kids is puberty is kid bodies changing into grown up bodies? That's what puberty is, right? And so, up until we start puberty, all kid bodies are essentially the same, except for our genitals. And if you have a pair of underwear on, you can't tell if a child is male or female or non binary or whoever they may identify by looking at their body because all by all kid bodies are essentially the same. It's all a matter of clothes and haircuts. But then when you get to puberty bodies start to change. And the hormones that are start circulating around puberty, start to develop what we call in the medical field primary and secondary sexual characteristics, which I also say is kind of feminizing and masculinizing characteristics. And so that starts to happen. And, you know, I also say, for those of you who are listening that are old enough to remember this movie, it's not like the movie Big with Tom Hanks, where you, you know, go to bed, a kid, and then you wake up and adult. So puberty happens over years, and there are stages of it. So the first stage of puberty typically starts between nine and 12, and progresses all the way until the late teenage years. And depending on if you were assigned female or assigned male at birth, there may be slightly different, typical starting and end points for that. But I think the main takeaway point is it is a process. There are stages, it happens slowly. And it happens over time. So I Is that helpful to kind of think through like what we're talking about when we say puberty?

Alex Iantaffi: 11:05

I think it's really helpful because I think that people when, you know, think that children are getting medical treatment of five or six years old, and like you said, you know, the treatment they're getting is a lot of conversation. And so when we're talking about puberty, a child is at least nine years old. And that is absolutely as early as puberty can start. I've even seen kids around eight years old, starting to develop kind of some, you know, starting to experience some pubertal changes, you know, so treatment doesn't medical intervention doesn't start that early. And then if there is medical intervention, what kind of medical intervention might happen during that window of pubertal changes? And what does it look like for trans and non binary or gender expansive children and youth?

Dr. Angela Goepferd: 11:56

Yeah, so the first treatment window would be at what we call in the medical terminology, Tanner stage two, which is that first stages of when those kid bodies start to change into grownup bodies. And so depending on again, the assigned sex at birth of the child, or the hormones that are circulating endogenously are sort of nataly in their bodies, that if you are assigned female at birth, the first signs of that puberty are going to be what we call breast buds are those little sort of pender pads of tissue that developed beneath the nipples for kids, where they often kind of feel them before you can even see them because they're kind of tender, and sometimes associated pubic hair. And then in kids who are assigned male at birth, it's often an enlargement of the testicles, which most kids may or may not notice. And then some associated pubic hair with a little bit of a voice change. That's kind of what starts to happen earliest on. And so when kids get to that stage, the second stage of puberty, that's where we have an opportunity to use a medication called a puberty blocker, or the medical term for those medications is a GnRH analog is what we call that. And that is a medication that can pause puberty, we say block, and sometimes we say stop, but I like to say pause, because specifically, it is a reversible medication. So we are literally pausing the pubertal hormones that are circulating, and therefore we can unpause them at any time. So in the work that I do with kids and families, puberty blockers are really nice option because kids actually don't have to have it all figured out at that stage. What they have to have figured out is that the changes that are happening in their body, don't feel right to them. They don't, they're causing distress, they're causing dysphoria, they're causing them to really feel uncomfortable, and it's specifically related to their gender identity. You know, puberty is not comfortable for anybody. So let's just get that on the table. No, kids love puberty. I mean, a handful of kids are excited about puberty. Most kids hate it, right. So it's not just not wanting to go through puberty, it's that your identity, your sense of self, your gender identity is specifically being contradicted by the changes that are happening in your body. And so that's an opportunity that we have to step in and pause that process.

Alex Iantaffi: 14:30

And that's an important distinction to make, because as a mental health provider who also works with this population. Often that's what I hear from parents, well, nobody likes puberty, puberty is uncomfortable for everybody. And then I have to kind of break it down. But for your kid, this seems to be uncomfortable in this very specific, gender related way, which is different than just experiencing the distress of puberty which is absolutely real and most people experienced that. There is an added kind of factor that is connected to their gender identity that their bodies kind of developing in a way that's not consistent or congruent with their version of themselves with their identity with, with who they are inside. Absolutely.

Dr. Angela Goepferd: 15:15

And I like the pause, I like to explain it as a pause, because, you know, the other thing that's beneficial about puberty blockers is, you know, it gives us some time. So it's a reversible intervention that if you have a kid who may be on the younger side, say, on the 9, 10, 11 year old side, and we, we are noticing that they're experiencing some distress around their gender identity, or some dysphoria around their gender identity, it's an opportunity for us to pause the permanent changes of puberty that are happening, which we don't talk about that enough, puberty is permanent. So we're very hesitant to make permanent changes in children or adults when it comes to initiating gender affirming hormones. But we sometimes forget that puberty is permanent. So we are committing a child to permanent bodily changes when we allow them to start to go through puberty. So we can pause that for a period of time to allow the child to work with practitioners like you and others, who can help them sort through some of these feelings to really delineate is this body discomfort? Is this gender discomfort? Is this what what is this that's going on? While we pause those permanent changes, and at any moment, we can unpause them, and allow kids to go through puberty, if we choose.

Alex Iantaffi: 16:30

Exactly because basically, then if you stop puberty blockers without any other hormonal intervention, the child would reverse to going through puberty in their basically gender assigned at birth, correct?

Dr. Angela Goepferd: 16:44

Correct. They would go through their what we call their natal puberty, or their puberty associated with their, their gender assigned at birth, from there, just as they otherwise would, so no long term changes or consequences. They they would progress. And, you know, these medications, that that we're talking about these puberty blockers, these have been around for over 30 years.

Alex Iantaffi: 17:09

And they were not developed for trans kids, right?

Dr. Angela Goepferd: 17:12

Absolutely not. Right, right. That's my...

Alex Iantaffi: 17:14

So who were they developed for. Do you know?

Dr. Angela Goepferd: 17:16

So well, you referenced this earlier on, you know, some kids do go through puberty, quite young, and probably the youngest age, we will let someone go through puberty, particularly if they're assigned female at birth is about eight. Eight would be pretty young for someone assigned male at birth. But there are some kids who under though that age do start to go through puberty. And that's just way too young. One of the primary processes that happens during puberty is if is if using of the growth plates, not only all of the secondary sexual characteristics, but really a mineralization of using of growth plates, and it just would stunt their development. So we can't let kids go through puberty that young. So these medications were developed to mimic the naturally occurring puberty hormone is GnRH, which then blocks the process downstream from that, to keep those kids going through early puberty that we call precocious puberty until they were of the age to keep up with their peers and start that puberty. So we may start these medications on a kid who's six or seven starting puberty too early, and keep their puberty on pause until they hit that 12 or 13 age and then take it off and have them go through puberty. So for over 30 years, we've had these medications, we've used them in kids who have puberty too early. And it's really in the last 20 years and probably more specifically in the last 10 years or so that we have used them for transgender and gender diverse kids, to pause their permanent changes of the puberty that's incongruent with their identity.

Alex Iantaffi: 18:46

And as far as I know, there was no big controversy, no legal challenges when this treatment was used for cisgender children were going through precocious, precocious puberty, which can be quite stressful. I mean, I remember I'm almost 50. And I remember growing up kind of peers, you know, in school kind of hitting puberty really early and out stressful. That was for them. And you know, I don't believe at the time there was any treatment or this treatment would have been really, really new, you know, and I was brought up prenatally, and that was something that wasn't even aware of until, like 25 years ago or something. So there were no controversy. So the controversy seems to be just applying this treatment that existed and was developed for cisgender kids to trans and gender expansive kids. What Why do you think that that's when it becomes controversial for people? Because medically doesn't seem to be any reason for it. Right? It seems to be.

Dr. Angela Goepferd: 19:46

I mean, it's a very it's a very safe medication. We've used it for a long time in kids with early puberty. There was, you know, to my knowledge, no significant controversy around using these medications and cisgender kids who are experiencing precocious puberty. And really, you know, there wasn't at least in the broader public, much controversy around these medications up until recently. So we've been, you know, the initiation of puberty blockers in trans and gender diverse kids started as early as I could find about 20 years ago. That's when our sort of studies on this started showing up. But you know, more I would say, more commonly, maybe in the last decade, and when, you know, scientists and physicians and other people who were prescribing these medications, endocrinologist, so the pediatric endocrinology society, experts in gender health, the, you know, World Professional Association for Transgender Health, the W, Pap, they developed guidelines around the use of these medications for a very long time, and no one cared. I mean, yeah, I'm sure there were people who cared, but you certainly didn't have bills about it. In the Senate, you certainly didn't have legal cases around it. And you certainly didn't hear about it in the mainstream as you do now. What's happening now is that we have the most visibility for trans and gender diverse folks than we have ever had. And anytime you have visibility for a population of people, whether it's trans and gender diverse people or people of a particular race, or religion, or whatever it is that the majority doesn't understand. It induces a fear based panic. And that's what we're seeing there is fear and misunderstanding, this is becoming more widely known, and people are panicking, based in fear, that it's not based in any of the good science that we've had over the last several decades, it's really a lot of fear. And so that's what I see happening now is, you know, there's a backlash, I think, happening to the trans visibility. We see that an increased violence against transgender bodies that is happening in this country, and I think all over the world as well. So it's kind of the price, I think we're paying for increased visibility for transgender people on transgender and gender diverse kids in particular.

Alex Iantaffi: 22:10

Absolutely, you know, it really feels like children's bodies are have become this kind of battleground, you know, around gender, which is kind of heartbreaking, because actually treatments like puberty blockers, like you said, this pausing creates so much space, for a really kind of healthy support for the child and for their family. It creates space, which was kind of only one to need during that time. And, and I think there there are so many misconceptions, like I've talked to people are like, the five is too young, for a child to transition. And I said children who are transitioning, so to speak up five, they're just socially transitioning, you know, their price that like you said, it's just the haircut or clothing, or changing the name, they're using a school. And usually those children who are socially transitioning, so young, are very strongly identifying a specific gender or they have a strong sense of self, which we don't usually challenges in cisgender children. If a child is gender, and they are assigned male at birth, and say, I'm a boy, when they're three years old, nobody goes, Don't you think you're a little too young to know if you're a boy, right? But the minute that somebody says, you know, they're assigned male at birth and says, I'm a girl, or they're assigned, you know, female at birth and says, I'm a boy and a girl, like, then there is all this questioning, you know, it's suddenly we no longer understand our gender identity development works on a psychological level, even though we have had theories for decades and decades that actually, yes, children.

Dr. Angela Goepferd: 23:44

Yeah, and, and Alex, I would even take that one step further to say, not only do we not challenge cisgender kids, we actively reinforce up their, their binary identities. So you know, when a three year old cisgender boy is expressing masculinity, it's all we can do to say he's such a boys boy, or she's such a girl's girl and we celebrate it. So we lean into and celebrate and reinforce binary identifications in cisgender kids, and we tolerate non binary identifications and, or presentations or expressions in some kids to some extent. Tomboys not so much femininity in boys. But, you know, when we have a kid who very strongly just like those boys, boys and girls, girl, yeah, it's clear with everyone in their life. I am a boy or I am a girl, even though that's not what you thought when I was born. We question them. We really question them that even though if that child had been assigned, you know, congruently in a cisgender way with their identification, we would celebrate it and reinforce it.

Alex Iantaffi: 24:56

Absolutely. And that's such an impact not just on trans, and gender expansive kids, but on all kids, I think because those cisgender children who do not fall into gender norms, you know, are also hearing this very kind of rigid binary like, what a strong boy you are. And really setting the precedents for boys can only be strong, you know, they're supposed to relate to others in a specific way. They're not supposed to feel fear or cry, or, you know, and of course, it's not always that rigid, but there is a certain rigidity to the binary that really impacts all kids in a harmful way, in a lot of ways. But yeah, thank you for kind of saying... Yes, not only do we not question them, yeah, we celebrate them and someone doesn't even serve them as kids.

Dr. Angela Goepferd: 25:45

Right. And I am all for celebrating kids, gender identities, I just want to celebrate all the kids gender identities, and not just the cisgender binary kids, I want to celebrate all the kids, I just want all kids to feel like they get to be who they know they are. And they get to express their identities in all the ways that feel comfortable to them.

Alex Iantaffi: 26:04

Absolutely. And in ways that are congruent with them, you know, like, right, my kid loves to talk about, you know, she has always had a strong like, I'm a girl identity as a sister, which also goes to show that having a transparent does not confuse your kids, she was brought up around all sorts of Trans and Queer non binary people. And she's never been confused about our gender, or other people's just to dispel another myth. But also this idea that you have to get girl in a specific way, right? She loves being a girly girl who's also really into science.

Dr. Angela Goepferd: 26:36

Yeah

Alex Iantaffi: 26:36

And of course, you know, that you don't have to be one thing or the other. Right, you don't have to be the stereotypes of gender, that I think we all end up promoting, if you're not careful.

Dr. Angela Goepferd: 26:49

Yeah, and, you know, in my, in my work, I think that's the gift that trans and gender diverse kids give all of us is that, when they're strong enough to be who they are, it allows the rest of us to be the full versions of ourselves. Because none of us are, you know, all one or all the other, you know, we don't all want to color with the blue crayon all the time, or all want to color with the pink crayon all the time, you know, a lot of us just want to explore all the parts of our identity. And so I feel like that's really, you know, in the face of this weaponizing of these trans kids bodies, which is so unfortunate, and putting them at the center of all this, the gift that they're giving us as a society is really allowing all of us to be the truest versions of ourselves, which we all deserve to be.

Alex Iantaffi: 27:33

Absolutely, and I love that there is something that we can give this kids to give them some space if they're experiencing distress, when those pubertal changes happen. And one of the things that I often hear from parents is this fear, you know, is this? Are there going to be side effects that I don't know, you know, about growth? Are there going to be cognitive effects? Are there going to be effects, not like bone growth, or bone density? I know that some of the concerns I hear about bone density are about cognitive changes. Can you speak to that a little bit to kind of, which is understandable. As a parent, you know, I'm also parent, I'm anxious sometimes if I'm considering a medical treatment for a kid, and I want to know, all the side effects but....

Dr. Angela Goepferd: 28:21

Yeah, absolutely and when we in medicine say that something is safe. We mean, it doesn't cause harm. But we don't mean it's without side effect, there is nothing that you can put in your body that is without a side effect, including the caffeine I'm ingesting as we're talking on this call. Right?

Alex Iantaffi: 28:39

Exactly.

Dr. Angela Goepferd: 28:39

I do that because it's safe. But it's not without side effects, right. So if I have too much of it, I'm going to be jittery and anxious. So this medications, these medications, these GnRH analogs are puberty blockers. They are not without side effects, though they are safe. And the most common sort of side effect that we talk about is relative to bone health. And what we found so one of the things that we know is that as kids go through puberty and puberty hormones are circulating in their bodies, specifically testosterone and estradiol or estrogen. One of the effects that it has on bones is something that we call bone mineralization, or a hardening of the bones. So during puberty is actually when kids should be getting a lot of calcium and vitamin D, whether that's through milk or otherwise. And often they're not unfortunately, but that's the time when their bones are becoming the strongest. And when we pause puberty, we're pausing the circulation of those hormones, those testosterone and estrogen hormones, and so we're interfering with that bone mineralization process. In the studies that were done on kids who had puberty suppression for early puberty, or precocious puberty. What we found was that after six or seven years on these blockers, there was noticeable difference in the bone density or hardening or bone mineralization between kids who were on the blockers and kids who were not. A few things about that. One, the good news is that the kids who had those noticeable changes once the blockers were stopped, and their puberty was resumed, when we remeasured them, their bone densities caught up. So it's not it wasn't a permanent change, it was a temporary change, and it caught up. The other good news is that the kids who got these medications for precocious puberty would sometimes be on them for six or seven years. It is very rare for a transgender or gender diverse child to be on them that long. So for most kids, I would say we're starting these around 10 11 12, sometimes even later, 13 14 15. And they're on them for typically two to four years. So less than that timeframe where we notice changes. That being said, because we know that it's a side effect, we check kids vitamin D levels, and make sure they're getting good calcium and vitamin D, while they're on treatment. We monitor their bones while they're on the treatment. So every two years, we check a scan to see how healthy and dense their bones are. And, and we follow that. And that's really the biggest side effect or risk that we know about in terms of the cognitive changes, we absolutely know that there are cognitive changes that happen during puberty, there are a lot of them. Your frontal cortex develops, your nerves, your nerves in your brain go through this process of pruning, or kind of weeding out all the stuff you don't know and solidifying the past that you really need in your in your brain. The studies that have been done have not shown any cognitive impact of puberty blockers. And again, my reassurance around it when I talk with families is that this we're not postponing puberty indefinitely, we're pausing it. So these hormones, whether it be the masculinizing, or feminizing hormones, will come into this child's body, at some point, it may be the ones that were going to be in their body, from their own ovaries or testicles, or it may be hormones that we give them as we induce the puberty that's congruent with our identity, but they will have these hormones. So I think that these cognitive processes are still happening, I don't think that they're exclusively ruled by testosterone and estrogen. And my, my confidence from the bone studies anyways, I think that this will catch up, the only thing I can really say to families is we don't have any evidence that there are cognitive effects of puberty blockers, it doesn't mean 100% that there aren't, but I don't have any evidence that there are. And, and that's really it. I mean, the bones continue to grow. There's another hormone called IGF one, which is a growth hormone that determines how tall you are. So you continue to grow taller, while you're on puberty blockers, you don't have the growth spurt that you would have when estrogen and testosterone come in, but you still continue to grow taller. So you know, the growth isn't stunted by being on these. And, you know, there's some fertility implications at these medications, which is a little bit more complex and involves whether you go on gender affirming hormones after or not. But in terms of a bad health outcome, initiated by the medication, there really are none. So it's, it's a really, that's why we say it's a safe medication.

Alex Iantaffi: 33:21

And it's a safe medication, which in my experience can have a life changing impact on sorry, the children I work with, because there can be such a level of distress, that really has incredibly negative impact on their mental health, you can be really prevented to a great degree by using puberty blockers. And I know that as a mental health provider, I have seen you know, young kids and young people really go from experiencing very high levels of anxiety or depression to actually being able to thrive and be almost completely different, sometimes overnight, just by having this anxiety about their body changing in a way that's distressing to them kind of being put on pause, like you said.

Dr. Angela Goepferd: 34:14

Absolutely.

Alex Iantaffi: 34:15

Right. I don't know if you, I'm sure you've witnessed that too.

Dr. Angela Goepferd: 34:18

Yeah, I mean, anecdotally, I see that all the time. Absolutely. I mean, they're, you know, two, I see two things, I see that the young kids who've identified early, they know puberty is coming. They're just terrified about it. They've been, you know, living in their, you know, the gender that's congruent with their identity for years now. And puberty is happening, and there's just panic. So to be able to relieve that panic for them, I mean, that it's just palpable. But then the other kids who are maybe a little bit later to their exploration and they're already have started puberty or they're early in puberty. I've had so many kids tell me just how much better they feel on the blockers. It just provides them a sense of relief that you know, biology, this train of puberty isn't just hurling down the tracks, I have their control. And we can say that anecdotally, but the other thing we can say is that we have evidence to really show that puberty blockers do make a difference. There have been several studies that show that mental health outcomes are improved in kids who are offered puberty blockers versus those who are not. And in fact, there was a study that was done, that was published in pediatrics in February of 2020 that for the first time really showed and in a study of 20,000, plus trans people, that there was statistically significant impact on suicidality. And kids who are transgender people who are transgender who were offered puberty blockers versus those who were not. So not only are their mental health markers better in terms of things like depression and anxiety, and just overall well being, but specifically, their risk of suicidality is lower on the puberty blockers. And I was reviewing that article right before we talked. And one of the things that I I must have missed when I read it last year, but it really just shown off the page when I read it today is that what was even more striking to me rereading it is that the transgender adults who wanted puberty blockers, but were not given them or offered them, nine out of 10 of them, 90% of them had suicidal ideation. So it was almost as if we were inducing suicidal ideation by withholding this treatment from those trans folks. And so for me, that's one of the things that with this decision in the UK, the Bell versus Tavistock decision, I just think of how much harm we are actually going to be causing to trans kids who we're going to be putting in a situation where they know that there's a treatment available to them. It's, it's one thing to not have a treatment option. Absolutely, it's a whole nother thing to know, there's something out there that you could access that would help you and you and you are being denied access to it. The impact on someone's mental health and the hopelessness that comes with that that can induce suicidality is really alarming to me.

Alex Iantaffi: 37:13

It is, and I think that's the part that should be alarming. And I get really sad when I hear people saying that's just big rhetoric that trans people are using, right, around suicidality, because actually, there is data, this is not rhetoric as data, like you said, 90% of you know, we now have adults who could have had this access to this treatment, but were denied it for whatever reasons 90%, you know, and and that is a vast majority. That's almost everyone. When we think about the fact that in the general trans population, we know that in our community, the level of suicidality is 10 times that of the general population, right. And that's not because we're trans. But because we live in a world where our identity and experiences are continuously kind of denied and raised or challenged, as we were saying earlier, 10 times that of the general population is a huge number you know, and knowing that this is one of the treatments that can make an incredible difference in the life of children and young people, that is a safe treatment, and they to reversible treatment.

Dr. Angela Goepferd: 38:23

Right.

Alex Iantaffi: 38:23

You know, there's nothing irreversible that happens with puberty blockers, right?

Dr. Angela Goepferd: 38:27

Right. Yeah. And I think, you know, the other point that we sometimes miss talking about when we talk about this is, you know, it's not just that we're relieving kids anxiety and treating the trans kids and gender diverse kids themselves, it's their parents too. It is not the parents of transgender and gender diverse kids who are advocating for this type of legislation. The people who are advocating for this know nothing don't aren't involved with don't have their own trans and gender diverse kids. The parents of trans and gender diverse kids want access to this treatment for their kids. I have kids in my practice, I have parents in my practice, I have one that I just interacted with within the last month, who is in the face of the Montana legislation, seriously considering relocating their family to Canada so that their trans daughter can have access to puberty suppression when she's of age, they want, they know the data, they know the science, they want their kids to have access to this treatment. And so we're also really, you know, harming families and the parents of these kids who know the benefits of this treatment for their trans and gender diverse kids and want them to have access.

Alex Iantaffi: 39:35

Absolutely. And like you said, puberty is actually not reversible. That's one of the things that sometimes I talk about with parents is, you know, this safe treatment could mean that your child does less or fewer invasive kind of surgical intervention later on. For example, a child was assigned female at birth might be able to have minimal intervention in terms of chest reconstruction or sometimes even no intervention, right, you know, compared to something like double mastectomy, which quite frankly, I went through as a trans and non binary adult, which is major surgery.

Dr. Angela Goepferd: 40:12

Right.

Alex Iantaffi: 40:12

You know, and so sometimes for parents kind of also thinking about what we might be... how this might be impacting their kid in the long run, right? Like you said, if they don't want any other medical intervention, puberty blockers, stop, everything goes back to how it was. But if they do want more medical interventions, it might save also folks who are assigned male at birth from really invasive kind of feminization procedure, or tracheal shavings, or all sorts of much more invasive surgical intervention, which again, not every trans person or non binary, or gender expansive person wants, but some people do need, actually not want, to need those to feel calm, right, within their body.

Dr. Angela Goepferd: 41:00

Yeah, absolutely, you know, the, the trans masculine kids that I care for the two biggest things that they experience, this worry about is their chest and their voice.

Alex Iantaffi: 41:08

Yes.

Dr. Angela Goepferd: 41:08

And, you know, with, with puberty blockers, we are taking away the chest dysphoria, if we started early enough for kids, they will never develop breasts, they will never have the surgery that you mentioned. And in trans feminine kids, the two biggest things that I hear about from them are also their voice, and their facial hair. And we can completely take that away with puberty blockers. And you know, once that voice lowers for trans feminine kids, that's a permanent change. And we estrogen doesn't raise it, there's no medical intervention we can do to raise that voice. And it is probably one of the most distressing you use your voice all the time, every day, it is so distressing for trans feminine, and particularly, you know, really female, binary feminine identified folks to have to learn how to handle that that voice. And again, with hair growth, you know, it's not, it doesn't go away with estrogen treatment, you have to have electrolysis or some painful procedure that is recurrent, to remove that, that hair and be able to give sort of our trans kids the freedom of not having to subject their bodies, to those kinds of painful medical interventions down the road, I think, is really a gift. And if you talk with trans adults who didn't have the option of puberty blocking treatment, many of them are very much in favor of offering this treatment for kids because of what they could have avoided if they had had access to.

Alex Iantaffi: 42:42

Oh, yeah, I mean, if I lived in a world where a. I didn't even realize that trans was a thing, you know, so I just knew that it was really cool that people thought I was a boy on the playground in the 70s. Right? How cool is that? But if an adult had been like more like, whoa, you know, how, who are you? And how would you feel, and I've been able to express that and have access to this treatment, life would have been so different. Well, I feel like I could talk about this, like for hours and hours, but I want to be respectful of your time, which I know is more precious than ever nowadays, as a medical provider. Is there anything that we haven't talked about that you would really like to communicate to people about puberty blockers and specifically, or just the treatment of kind of gender expansive youth for anything that we haven't covered that you think it's important to name?

Dr. Angela Goepferd: 43:34

You know, I think we covered a lot of it, you know, I really just want people to understand what the medication is that we're talking about when we use it, the fact that it is reversible. The fact that we know that it's very safe that we've studied, studied it, and both cisgender and transgender kids for several years. I also you know, just because I work so closely with trans and gender diverse kids, I, I really want to reinforce that. Kids do know who they are. And, you know, we all go through a process of identity development that happens our whole lives, I am not the same person at 43, as I was at 33, or 23, or 13 or seven. I have grown and developed over that time. And even for me, there's been some validity to my gender identity during that time. But we all get permission to go on that journey. And it's not for us to stop our, you know, children and adolescents from going on that journey. Particularly when they are very convicted about it. And when you have a medical team and a mental health team, that is you know, absolutely convinced that this is the best best path for a child and parents who are supportive. I would really hate to see there be legislation that prevents good outcomes, both physical and mental health outcomes for kids. And, you know, I really just hope that we continue to listen to kids and let them continue to change the world and us right along with it. Because I think we'll all be better for that in the end.

Alex Iantaffi: 45:03

I agree. I mean, the kids I work with know they are they know what they want. And if we just listen to them, and like you said, it's not also no treatment is given on a whim, right? There's like X rays involved and blood work and seeing a medical doctor and often seeing a mental health provider. This is a very involved process. It's not like everybody goes in for one and done visit for puberty blockers, right?

Dr. Angela Goepferd: 45:32

Right.

Alex Iantaffi: 45:32

Yeah, this is something that can really make such a positive impact in the life of people and that probably legislators should stay well the hell out of I would say, it's not their job. Let's just let the medical providers do their job. Right?

Dr. Angela Goepferd: 45:47

Right. Yes. Well, thank you, Alex, for having me. I really appreciate it.

Alex Iantaffi: 45:52

Thank you. Thank you. Thank you so much for sharing all this wisdom and this knowledge with the gender stories listeners. I also hope the listeners that you go check out Kade's TEDx talk is really good. So you should watch it. And then as ever, in the episode description, there'll be some links for you to look at about some of the things that we've been mentioning. And thank you so much again, Dr. Goepferd for being on the show today.

Dr. Angela Goepferd: 46:17

Absolutely.