Pediatrician Cara Natterson, MD, and puberty educator Vanessa Kroll Bennett have created this guide to help parents, guardians, and other adults learn more about our current understanding of puberty and how to help our kids through it. Unfortunately, the book includes a number of misleading and dangerous errors, particularly around trans youth, even though at points it tries to take an inclusive view of gender identity and sexual orientation.
Puberty, say Natterson and Bennett, now starts an average of two years earlier than when most current parents went through it, often lasts longer, and happens in a world of social media and other changes. It therefore behooves parents to understand what puberty means today—including not only sexual maturation but also, as the authors define it, all of the other changes associated with adolescence.
Chapters cover physiological topics like genitalia, periods, breasts, hair, acne (on faces and elsewhere), body odor, and growth spurts, plus psychological areas such as sleep, brain development, mood swings, and mental health. Other chapters look at body image and eating disorders, youth sports overspecialization, sex (including hookup culture and porn), contraception, STI’s, and STDs, and friendships and peer influence. Gender identity and sexual orientation each get a dedicated chapter as well. Most chapters are helpfully broken down into four parts: the science behind the topic in question; how things have changed in our understanding of it over the past few generations; how to talk about it with kids; and first-person insight from young adults who recently went through puberty.
The most important takeaway, the authors stress, is that “the physical changes of puberty are starting earlier, but brain maturation isn’t happening any faster.” We should therefore remember to “Treat [kids] how old they are, not how old they look.” That feels like wise advice, as is much of what they say about children in general.
Let’s look more closely at some of the problematic areas, however.
Gender-Affirming Care
Most critically, the authors err in their discussion of gender-affirming care for trans youth. As I read it, this is more because of poor research and editing than because of any deliberate anti-trans intent on the part of the authors, who seem generally affirming of trans identities, noting, “A person’s assigned sex at birth is distinct from their gender identity,” and that “Ultimately, the goal for any kid of any gender is to find the fullest, most joyful expression of themselves.” They even assert that “Puberty blockers can be life altering and lifesaving.”
Nevertheless, there is problematic content here. I freely admit I am not an expert on trans youth, am not trans myself, and am relying on the work of others I know and trust. I hope my criticism is enough to caution readers and to have the authors and publisher reach out for further input to respected medical professionals who provide gender affirming care to trans youth. First, the authors note, “While most medical organizations recommend waiting on surgeries until at least age 18, the age of consent, several advocacy groups have pushed to accelerate this by as much as three years, consistent with the laws and recommendations of many countries across the globe.”
The sweeping nature of that statement, not distinguishing “top” and “bottom” surgeries, is misleading. Gender-affirming bottom surgeries before age 18 are extremely rare, and I know of no organizations that are pushing for it. While there are some small number of top surgeries (fewer than 300 per year according to one study of full or partial health insurance claims for about 330 million U.S. patients over the five years from 2017 to 2021), they are done on a case-by-case basis, with input from parents and doctors. As the National Center for Transgender Equality notes, “Any surgical care for teenagers under 18 is rare and individualized. It is carefully examined under the supervision of medical professionals using standardized, evidence-based guidelines.”
The book also includes the below passage (my bold), which I’m quoting at length so I can be as clear as possible in my critique:
Advocacy groups are working hard to help guide these conversations [around gender identity and gender affirming care], as evidenced by the American Academy of Pediatrics’ 2018 policy statement on the importance of gender-affirming care; in 2022, the AAP doubled down in the face of legislative efforts attempting to block the multidisciplinary approach to supporting transgender and gender-diverse kids across a number of states.
If the front-and-center conversations about gender feel very new, especially with respect to kids, there’s good reason. The very first pediatric gender clinic in the United States opened at Boston Children’s Hospital in 2007, a mere 15 years ago. That’s not much time to digest language and notions, let alone medical conventions, which explains sometimes-fierce debates over gender-affirming care strategies like hormone therapy. Some say it shouldn’t start until a child is at least 16, while others disagree with a chronological time line and think it should depend upon a particular child’s path through their gender identity. As of the writing of this book in 2023, the average age to begin taking hormones is somewhere between 14 and 16 years old, with many (but not all) starting puberty blockers first. By the time these words are printed on a page, the numbers—and opinions—will have undoubtedly shifted again.
Dating the treatment of trans youth from the founding of the Boston Children’s clinic “a mere 15 years ago” is misleading, making it seem much more newfangled than it is. Gender-affirming care for youth has built upon the pioneering efforts in the Netherlands in the late 1990s. Puberty blockers have in fact been used since the 1980s to treat non-trans children for things like “precocious puberty.” GnRHa (a puberty blocker) was first used in the treatment of gender dysphoria in 1988. Both the Royal College of Psychiatrists and the World Professional Association for Transgender Health (WPATH) recommended it as the standard of care for dysphoric adolescents in 1998. Additionally, as HRC observes, even in the very rare cases of minors having gender-affirming surgeries, “They are the same procedures that have safely and effectively been given to cisgender and intersex people for decades, for a host of cosmetic and medical reasons.”
Next, while the book rightly notes the AAP’s 2018 policy statement, it should have mentioned that the policy is based on research and clinical guidelines. Also, it’s not just the AAP. As the American Medical Association (AMA) has said (my bold):
Clinical guidelines established by professional medical organizations for the care of minors promote these supportive interventions based on the current evidence and that enable young people to explore and live the gender that they choose. Every major medical association in the United States recognizes the medical necessity of transition-related care for improving the physical and mental health of transgender people.
Nevertheless, Modern Puberty Explained continues:
Much of the criticism of treatment centers on detransitioners, people who went through the transitioning process to some degree only to reverse course. It’s one thing for a child to opt for new pronouns for a few years and then rethink the idea, and another thing entirely to have surgery and do the same. Detransitioning hasn’t been very well studied (how could it be, since transitioning at increasingly young ages is so new), but one recent small study of 100 detransitioners found these reasons for going back on the choice:
- Thirty-eight percent believed their gender dysphoria had been caused by a trauma or underlying mental health condition.
- Fifty-five percent felt they didn’t receive an adequate evaluation from a doctor or mental health professional before starting transition.
- Twenty-three percent cited experiencing discrimination after transitioning or having difficulty accepting themselves as lesbian, gay, or bisexual.
- Forty-nine percent were concerned about potential medical complications from transitioning.
- Sixty percent simply became more comfortable identifying as their natal sex.
The book presents the “criticism of treatment” as if it represents a legitimate opposing stance, not noting that it is coming from a vocal minority of people on the far right (and those who follow their arguments), against the overwhelming majority of medical research and professional guidelines. To include it here feels like an egregious example of bothsidesism.
Additionally, the line about “rethinking” transition, particularly after surgery, implies that a) many trans kids are having surgeries (which I debunked above); and b) many of them are then detransitioning. There are a number of studies showing that detransitioning among trans youth is extremely rare; here’s one, and another, and another, to cite just a few. When it comes to surgery, one recent study found that less than 1% of trans men who had top surgery before the age of 18 had regrets. Contrast this with a study that found approximately 5% of cisgender women regret breast reduction surgery. Using so much space to talk about a study of detransitioners and the reasons someone might detransition, without ever noting just how rare detransitioning is, is irresponsible and misleading.
Furthermore, the “recent small study” that they cite is by Lisa Littman, whose work on trans youth and theory of “rapid onset gender dysphoria” (the idea that someone can suddenly become dysphoric from the influence of friends or social media) has been criticized, disproven, and debunked, and even rejected in a statement by the American Psychological Association and just about every other major psychological and psychiatric organization in the U.S. The Littman study cited in Modern Puberty Explained, however, says, “The data in this study strengthen, with first-hand accounts, the rapid-onset gender dysphoria (ROGD) hypotheses.” The puberty book doesn’t say anything about ROGD, but in citing someone whose (discredited) work has been frequently wielded by anti-trans activists as a tool against trans youth and in support of anti-trans legislation, it undercuts its seemingly inclusive message.
The book’s slipshod coverage of gender-affirming care is a showstopper for me. I’m going to point out a few lesser issues below, too; while not quite as problematic, they deserve to be addressed.
Types of Sex
For the oldest children, the authors suggest explaining the various kinds of sex, including “vaginal, anal, oral, and masturbation.” They also remind readers not to make assumptions about their child’s sexual orientation. That’s terrific. Nevertheless, the framework they suggest for talking with kids about sex leaves something out. They write, “Our favorite way of approaching the biological aspects goes like this: There are four different kinds of sex: vaginal sex, oral sex, anal sex, and masturbation.” They then recommend explaining each one and answering any questions a kid might have.
So far so good. But vaginal sex is described solely as “vaginal intercourse” involving penetration, whether by penis, fingers, sex toys, or the like. What’s left out is sex involving genital-to-genital contact or hand-to-genital contact that doesn’t involve penetration (and isn’t masturbation, defined here as “sex with yourself”). While people of any sexual orientation may engage in these non-penetrative forms of sex, these are particularly common (in my unscientific but somewhat knowledgeable opinion) among us queer folks. (Google “scissoring,” for example.) That means that the book’s call to “make sure to be inclusive of types of sex other than heterosexual, penis-in-vagina” falls a little flat.
Terminology
There are a also a number of places where I feel terminology needs change or clarification, though none of these are big errors:
- While the authors rightly acknowledge the shifting terminology related to sexual orientation and gender identity, they also assert, “As of the writing of this book, the most inclusive oft-used version stands at LGBTQIAA+,” and this is the term they use throughout the book. I’d disagree that it’s “the most inclusive oft-used version,” however, if only because “LGBTQIA2S+” is an equally (but differently) inclusive version, and a comparison of LGBTQIAA+ vs. LGBTQIA2S+ as search terms shows that LGBTQIA2S+ has the edge (and both are far below either “LGBTQ+” or “LGBTQIA+”). In fact, if you Google “What does LGBTQIAA+ stand for?” Google brings back results for “LGBTQIA+”, meaning that the double-A version is much rarer. The use of LGBTQIAA+ isn’t wrong, but saying that it’s “oft-used” feels off.
- While they define one of the two A’s as “asexual,” they also say the second A “can also = Ally”—but I’ve also seen the second A (on the rare occasions it’s used) defined as agender or aromantic (which are not mentioned in the book), with some queer people feeling that “allies” are not part of the queer community per se. (See this article from Everyday Feminism and this article from Matthew’s Place, a project of the Matthew Shepard Foundation, to cite just of many two sources.) The book isn’t really wrong, as the second A “can” mean ally, but I would have at the very least included agender and aromantic as alternate meanings.
- On one page, they use the dated term “preference” to refer to sexual orientation and gender identity.
- It feels odd that there’s a chapter titled “Penises and Testicles” but not one on “Vaginas and Vulvas.” Instead, female genitalia are covered in a chapter titled “Periods” (with a little more about the clitoris in the chapter on sex). This isn’t the worst thing, but feels like it’s saying all we need to know about female genitalia relates to menstruation. (Maybe “Vaginas, Vulvas, and Periods” would be the way to go if they want to highlight periods in the title, too.)
- A reference to “Human Rights Commission websites” as a source for information about gender identity should, I believe, be “Human Rights Campaign websites,” referring to the largest LGBTQ advocacy organization. As the source is not clarified in the endnotes, I am not 100% certain about which organization they mean, but I hope that an editor will check this.
The book’s treatment of gender-affirming care means I cannot recommend it as it now stands. I hope we might see a revised edition in the future, though, for much of its other information about puberty seems useful indeed to people guiding their children through this transformational time of life.
