Puberty blockers for transgender and gender-diverse youth

Puberty blockers can be used to delay the changes of puberty in transgender and gender-diverse youth who have started puberty. The medicines most often used for this purpose are called gonadotropin-releasing hormone (GnRH) analogues. Here's a summary of their possible benefits, side effects and long-term effects.

What do puberty blockers do?

When taken regularly, GnRH analogues stop the body from making sex hormones. That includes testosterone and estrogen.

Sex hormones affect:

• Primary sex characteristics. These are the sexual organs present at birth. They include the penis, scrotum and testicles, and the uterus, ovaries and vagina.
• Secondary sex characteristics. These are the physical changes in the body that appear during puberty. Examples include breast development and growth of facial hair.

In people assigned male at birth, GnRH analogues slow the growth of facial and body hair, prevent voice deepening, and limit the growth of the penis, scrotum and testicles.

In people assigned female at birth, this treatment limits or stops breast development and stops menstruation.

What are the possible benefits of puberty blockers?

Gender identity is the internal sense of being male, female, neither or some combination of both. Gender dysphoria is a feeling of distress that can happen when gender identity differs from a person's sex assigned at birth or from sex-related physical characteristics. Some transgender and gender-diverse people experience gender dysphoria. Others do not.

For transgender and gender-diverse youth who have gender dysphoria, delaying puberty might:

• Improve mental well-being.
• Ease depression and anxiety.
• Improve social interactions with others.
• Lower the need for future surgeries.
• Ease thoughts or actions of self-harm.

Taking puberty blockers alone, however, without other medical or behavioral treatment, might not be enough to ease gender dysphoria.

What are the criteria for use of puberty blockers?

In most cases, to begin using puberty blockers, an individual needs to:

• Show a lasting pattern of gender nonconformity or gender dysphoria.
• Have gender dysphoria that began or worsened at the start of puberty.
• Address any psychological, medical or social problems that could interfere with the treatment.
• Be able to understand the treatment and agree to have it. This is called informed consent.

Puberty blockers are not recommended for children who have not started puberty.

In most cases, youth aren't old enough to get medical treatment without a parent, guardian or other caregiver's permission. This is called medical consent. For those who haven't reached the age of medical consent, a parent, guardian or caregiver often needs to agree to the use of puberty blockers. Parent and family support and encouragement also has been shown to be an important part of boosting mental health and well-being throughout this treatment.

Are the changes permanent?

GnRH analogues don't cause permanent physical changes. Instead, they pause puberty. That offers a chance to explore gender identity. It also gives youth and their families time to plan for the psychological, medical, developmental, social and legal issues that may lie ahead..

When a person stops taking GnRH analogues, puberty starts again.

When does treatment usually start and end?

In general, puberty begins around age 10 or 11, though it may start earlier or later. The effect of puberty blockers depends on when a person begins to take the medicine. GnRH analogue treatment can begin at the start of puberty to delay the development of secondary sex characteristics. In slightly later stages of puberty, the treatment could be used to stop menstruation or erections. It also may prevent further development of secondary sex characteristics.

While many people take the medicine for a few years, everyone is different. After delaying puberty for several years, some teens might decide to stop taking puberty-blocking medicine. Or they may start taking hormones that match their gender identity. This is called gender-affirming hormone therapy.

How is the medication given?

GnRH analogue medicine is prescribed, given and monitored by a health care professional who has expertise in this group of medicines. The medicine typically is given as a shot either monthly, every three months or every six months. Or it may be given as an implant placed under the skin of the upper arm. The implant usually needs to be replaced every 12 months.

While taking puberty blockers, regular blood tests are needed to check the medicine's effectiveness. Regular appointments with the health care team to check for side effects also are important.

What are the possible side effects and complications?

Possible side effects of GnRH analogue treatment include:

• Swelling at the site of the shot.
• Weight gain.
• Hot flashes.
• Headaches.
• Mood changes.

Use of GnRH analogues also might have long-term effects on:

• Growth spurts.
• Bone growth.
• Bone density.
• Fertility, depending on when the medicine is started.

If individuals assigned male at birth begin using GnRH analogues early in puberty, they might not develop enough skin on the penis and scrotum to be able to have some types of gender-affirming surgeries later in life. But other surgery approaches usually are available.

Those who take GnRH analogues typically have their height checked every few months. Yearly bone density and bone age tests may be advised. To support bone health, youth taking puberty blockers may need to take calcium and vitamin D supplements.

It's important to stay on schedule with all medical appointments. Between appointments, contact a member of the health care team if any changes cause concern.

What other treatments are needed?

Assessment and counseling by a behavioral health care professional can help youth and their families as they move through the decision-making process about puberty blockers. Behavioral health care also is an important source of support while taking puberty blockers. Talking about an individual's gender identity with teachers, school staff, and staff in other organizations in which the youth is involved also may help ease social adjustment during this time.

After a time of adjusting to puberty blockers and confirming gender identity, gender-affirming hormone therapy might be an option. This can develop masculine or feminine secondary sex characteristics to help better align the body with an individual's gender identity. Some of the changes triggered by gender-affirming hormone therapy cannot be reversed. Others may require surgery to reverse.

GnRH analogues are the most common medicines used to delay puberty. But they are not the only medicines that can be used. Talk to a member of the health care team for information about other treatment choices.