Stuck in the Middle: Puberty Blockers and the Risks for Body Dysphoria
Cross-sex hormones often lead to bodies that fall between the sexes, raising questions about their ability to relieve dysphoria.
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About the Author
Dr. Greg Brown is a professor of Exercise Science at the University of Nebraska at Kearney where he also serves as the Director of the LOPERs General Studies program. He is a member of the American College of Sports Medicine (ACSM), the National Strength and Conditioning Association (NSCA), and the Association of American Educators (AAE).
We’ve all heard it so often that many of us can recite the definition of gender dysphoria from memory. But just to be clear: gender dysphoria is a psychological condition in which a person experiences significant distress or discomfort due to a supposed mismatch between their “gender identity” (often construed as a person’s internal sense of being a boy or girl, a man or a woman) and their biological sex.
Body dysphoria, though less commonly discussed, refers to intense dissatisfaction or discomfort with one’s physical body. While it’s not a formal clinical diagnosis on its own, the term frequently appears in discussions related to gender dysphoria, body image issues, and eating disorders.
The most common justification for using puberty blockers, testosterone suppression, and estrogen in trans-identified girls (i.e., boys who identify as girls) is that this so-called gender-affirming hormone therapy (GAHT) is intended to help align their physical appearance with their gender identity. In theory, GAHT is meant to reduce both gender and body dysphoria by halting male puberty and promoting the development of female secondary sex characteristics.
However, major evaluations—including the Cass Review¹ and a report from the U.S. Department of Health and Human Services²—have found little to no even moderate-quality evidence that these interventions alleviate gender dysphoria or lead to improved long-term health outcomes. In fact, emerging research suggests that these treatments often result in bodies that don’t clearly align with either typical male or female traits.
This raises an important question: If someone’s gender identity is based, at least in part, by traditional gender norms—like how men and women are “supposed” to look—then how does ending up with a body that doesn’t clearly resemble either sex actually help?
Physical Development Under GAHT
One of the most obvious physical differences between males and females is height. On average, adult men are about five inches (12.5 cm) taller than adult women. Even a woman in the 95th percentile for height is still only slightly taller—by less than a quarter of an inch (0.5 cm)—than a man at the 50th percentile. While puberty blockers can delay the typical adolescent growth spurt (known as peak height velocity), once a male child begins estrogen therapy, they still undergo a growth spurt and generally reach heights typical of adult males. This was documented in the aptly titled 2022 paper “Transgender Girls Grow Tall”³, as well as in a 2023 follow-up study⁴.
Another prominent sex-based difference is shoulder-to-hip ratio. Men usually have broader shoulders and narrower hips compared to women. Estrogen can cause some widening of the hips in males, even when introduced after the onset of male puberty, though the effect is modest. The widening may be somewhat more pronounced if estrogen is started early in conjunction with puberty blockers⁵⁻⁶.
However, estrogen does not make shoulders narrower. Even when puberty blockers are introduced very early and followed by estrogen therapy, the shoulders still tend to develop in a male-typical way. Most trans-identified males, even those who begin transitioning in early adolescence, will likely have broader shoulders than typical adult females⁶.
Body fat distribution also varies significantly by sex. Women tend to have a higher percentage of body fat overall (typically 25–31 percent) compared to men (around 18–24 percent), and they store more of it in the hips and thighs. Men, by contrast, accumulate fat around the abdomen and chest⁷. Suppressing testosterone and introducing estrogen increases overall body fat and shifts fat distribution toward a more female pattern. Still, even with early intervention, the final outcome rarely mirrors that of a typical female⁸⁻¹⁰. A trans-identified male may end up with more body fat than a typical male, but less than a typical female—and distributed in a way that resembles neither sex.
Muscle mass is another significant physical difference. Males naturally develop more muscle than females, particularly in the upper body. While GAHT can reduce muscle mass and strength, it does not eliminate male-typical advantages. Even after years of hormone treatment, transwomen tend to retain more muscle than women⁸⁻¹⁰. Puberty blockers may slow the muscle development that occurs during male puberty, but the sex-based gap in muscle mass is not fully closed.
Breast development is perhaps the most visibly gendered secondary sex characteristic. While males typically lack breast tissue—aside from cases of gynecomastia¹²—most transwomen desire breast development as part of their transition. After approximately three years of estrogen therapy, transwomen typically develop small breasts, often smaller than an A cup. These breasts also tend to sit lower on the chest and further to the sides than is typical in females¹³.
Boogers et al.⁶ have suggested that early use of puberty blockers, combined with optimal estrogen formulations, might result in more developed and naturally placed breasts in transwomen—possibly reaching B or even C cup sizes. However, this remains speculative, as no robust studies have confirmed these outcomes.
The Problem of Physical Ambiguity
There is very limited long-term data on the full effects of GAHT on height, body composition, or musculoskeletal development in children who begin treatment early and continue into adulthood. However, current evidence suggests that a teenage boy who starts puberty blockers for several years and then takes estrogen for another six will likely develop into a transwoman who is tall like a man, has broader shoulders, a somewhat feminized pelvis, and a mix of male and female body fat and muscle characteristics. This person may also develop small, lower-set breasts that differ in both placement and volume from typical female breasts.
If a person’s gender identity is shaped in part by traditional expectations of male or female appearance, this hybrid physical outcome may fall short of their hopes—or fail to resolve their dysphoria. Which leads to a fundamental question:
If someone’s gender identity is based on conventional gender norms—such as how a man or woman is “supposed” to look—how does ending up with a body that resembles neither sex actually help?
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REFERENCES:
1. NHS England. The Cass Review Independent review of gender identity services for children and young people. final report. April 2024. https://webarchive.nationalarchives.gov.uk/ukgwa/20250310143933/https://cass.independent-review.uk/home/publications/final-report/
2. U.S. Department of Health and Human Services. Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices. May 1, 2025. https://opa.hhs.gov/gender-dysphoria-report
3. Boogers LS, Wiepjes CM, Klink DT, Hellinga I, van Trotsenburg ASP, den Heijer M, Hannema SE. Transgender Girls Grow Tall: Adult Height Is Unaffected by GnRH Analogue and Estradiol Treatment. J Clin Endocrinol Metab. 2022 Aug 18;107(9):e3805-e3815. doi: 10.1210/clinem/dgac349. https://academic.oup.com/jcem/article/107/9/e3805/6603101?login=false
4. Ciancia S, Klink D, Craen M, Cools M. Early puberty suppression and gender-affirming hormones do not alter final height in transgender adolescents. Eur J Endocrinol. 2023 Sep 1;189(3):396-401. doi: 10.1093/ejendo/lvad125. https://academic.oup.com/ejendo/article-abstract/189/3/396/7273069?redirectedFrom=fulltext&login=false
5. van der Loos MA, Hellinga I, Vlot MC, Klink DT, den Heijer M, Wiepjes CM. 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. J Bone Miner Res. 2021 May;36(5):931-941. doi: 10.1002/jbmr.4262. https://academic.oup.com/jbmr/article/36/5/931/7516806?login=false
6. Boogers LS, Sikma BT, Bouman MB, van Trotsenburg ASP, den Heijer M, Wiepjes CM, Hannema SE. Shaping the Skeleton: Impact of GnRH Analogue and Sex Hormone Therapy on Skeletal Dimensions in Transgender Individuals. J Clin Endocrinol Metab. 2025 Apr 22;110(5):e1411-e1419. doi: 10.1210/clinem/dgae574. https://academic.oup.com/jcem/article/110/5/e1411/7734697?login=false
7. ACSM. (2025). ACSM's Guidelines for Exercise Testing and Prescription (C. Ozemek, Ed. 12th ed.). Lippincott Williams & Wilkins.
8. Ciancia, S., Dubois, V., Craen, M., Klink, D., Verroken, C., Vanderschueren, D., & Cools, M. (2024). Effects of puberty suppression on bone, body composition, handgrip strength and glucolipid profile in early-pubertal transgender adolescents. International Journal of Transgender Health, 1–13. https://doi.org/10.1080/26895269.2024.2353224
9. Klaver M, de Blok CJM, Wiepjes CM, Nota NM, Dekker MJHJ, de Mutsert R, Schreiner T, Fisher AD, T'Sjoen G, den Heijer M. Changes in regional body fat, lean body mass and body shape in trans persons using cross-sex hormonal therapy: results from a multicenter prospective study. Eur J Endocrinol. 2018a Feb;178(2):163-171. doi: 10.1530/EJE-17-0496. https://academic.oup.com/ejendo/article-abstract/178/2/163/6655302?redirectedFrom=fulltext&login=false#google_vignette
10. Klaver M, de Mutsert R, Wiepjes CM, Twisk JWR, den Heijer M, Rotteveel J, Klink DT. Early Hormonal Treatment Affects Body Composition and Body Shape in Young Transgender Adolescents. J Sex Med. 2018a Feb;15(2):251-260. doi: 10.1016/j.jsxm.2017.12.009. https://academic.oup.com/jsm/article-abstract/15/2/251/6980279?redirectedFrom=fulltext&login=false
11. Hilton EN, Lundberg TR. Transgender Women in the Female Category of Sport: Perspectives on Testosterone Suppression and Performance Advantage. Sports Med. 2021 Feb;51(2):199-214. doi: 10.1007/s40279-020-01389-3. Erratum in: Sports Med. 2021 Oct;51(10):2235. doi: 10.1007/s40279-021-01480-3. https://link.springer.com/article/10.1007/s40279-020-01389-3
12. Ayyavoo A. Gynecomastia. Indian J Pediatr. 2023 Oct;90(10):1013-1017. doi: 10.1007/s12098-023-04810-7. https://link.springer.com/article/10.1007/s12098-023-04810-7
13. de Blok CJM, Dijkman BAM, Wiepjes CM, Staphorsius AS, Timmermans FW, Smit JM, Dreijerink KMA, den Heijer M. Sustained Breast Development and Breast Anthropometric Changes in 3 Years of Gender-Affirming Hormone Treatment. J Clin Endocrinol Metab. 2021 Jan 23;106(2):e782-e790. doi: 10.1210/clinem/dgaa841. https://academic.oup.com/jcem/article/106/2/e782/5988990
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What a sensible review from the heartland of America! As a retired pediatrician, I find this evidence-based review refreshing and informative. It seems to suggest that these medical therapies largely fail in attaining their physical and psychological targets. For the first time in my 77 years, I have found a good role for plaintiff's lawyers. Sue the physicians and hospitals who hopped on this bandwagon and brought enormous and irreversible damage to troubled young people!
I think there was an error:
All children exposed to estrogen during puberty halt long bone growth fairly quickly. Estrogen triggers the epiphyseal plate to ossify or fuse which locks height in.
Girls at puberty are taller than boys because puberty and growth hormone starts earlier. They also cease growing earlier because of estrogen and earlier cessation of puberty.
Boys get estrogen through a process of aromatisation, converting testosterone to estrogen; this takes some time to build up estrogen, so boys grow taller than girls usually, since girls have estrogen quite quickly from functioning ovaries which halts their long bone growth.
The paper mentioned was relative to reduction in testosterone, not supraphysiologic doses of “estrogen”
Chemically sterilizing a boy will allow them to grow quite tall, unless estrogen receptors in their epiphyseal plate are irreversibly triggered.
Girls chemically sterilized before epiphyseal plate fusion will also grow quite tall.
https://pmc.ncbi.nlm.nih.gov/articles/PMC34445/#:~:text=In%20some%20mammals%2C%20including%20humans,men%20and%20women%20(10).
This is well-known by endocrinologists and has been used by some to predict “too tall girls” and they are given excess estrogen to make sure “they are not too tall”, a fairly terrible things.
Secondarily, men who have been castrated - castrati - grow extremely tall.
So, in all cases - boys and girls - chemically (or surgically) sterilizing them will cause abnormal growth in long bones unless their growth is suppressed with estrogen.
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Most of the other observations are correct, but the child is never “in between” sexes.
With no estrogen they appear as abnormally tall children (Castrati), and in the case of female.
With excess testosterone, women will have some masculinized hair patterns - but facial and chest hair is not unknown on women. They will bone problems I suspect because they will have insufficient testosterone for aromatisation to estrogen for healthy development. They will also undergo premature menopause.
Boys will grow abnormally tall without supplemental estrogen, and without testosterone key parts of their body won’t mature - circulatory, cognitive, and muscular.