Puberty blockers
The changes to your body that happen during puberty can be distressing if they are not aligned with your gender. Puberty blockers can help relieve this distress.
Delaying puberty gives a person more time to understand, make decisions and plan ahead before changes (that can’t be reversed) happen to their body. For youth who are in early stages of puberty, pausing the advancement of further changes can significantly reduce distress that puberty may be causing.
What are puberty blockers
Puberty blockers are medications that suppress the sex hormones that are produced by the body. These medications may be started soon after puberty begins. They put puberty on pause and can prevent changes such as voice lowering, breast growth and periods. Effects will vary, depending on how far puberty has progressed before starting the blockers.
Once puberty blockers are stopped, puberty will resume. If a youth begins hormone therapy, puberty-related changes will resume but in a way that aligns with their identity. These medications have been safely used for decades to treat children who started puberty too early, and were first used with trans youth in the 1990s.
The three most common reasons that youth use puberty blockers are:
- The idea or reality of developing secondary sex characteristics that do not fit with their gender can be very distressing. Puberty blockers can help alleviate this distress.
If a child or youth is still exploring their gender, puberty blockers allow additional time for planning and decision-making without worrying about unwanted physical changes.
Preventing unwanted physical changes can eliminate the need for some surgeries and procedures later on, such as chest construction surgery and hair removal.
Overall, research indicates puberty blockers are safe and effective in supporting wellbeing, reducing distress, and providing more time for trans youth to make decisions about gender-affirming care.
Puberty blockers are often prescribed by a pediatric endocrinologist. However, pediatricians and primary care providers who are knowledgeable about trans care may provide this care as well.
The time sensitivity of puberty blockers
For those who need puberty suppression, timely access is very important. Due to the distress that can come with oncoming or advancing puberty, the need for puberty blockers can become very time sensitive and delays can cause additional distress leading to an increased risk of mental health issues.
Access to puberty blockers at the right time helps a young person avoid irreversible changes associated with puberty and ultimately ensures they develop secondary sex characteristics that are consistent with their gender.
Because accessing this care can take some time and involves a number of care planning steps (such as a readiness assessment), it’s important to begin the process as early as possible.
Starting puberty blockers
If a young person is under the age of 19, the process of accessing puberty blockers can take some time. For this reason, it’s a good idea to familiarize yourself with the process as soon as child may need this care.
Readiness assessment
Starting puberty blockers is a big decision, and support from family and health care providers is important. Assessment and care planning may be provided by a number of professionals who have received advanced practice training in this area of care. These may include a pediatrician, psychologist, psychiatrist, nurse, social worker, family doctor or nurse practitioner.
- The role of the clinician doing the readiness assessment is to:
- Support decision-making around interventions
- Provide accurate information about effects, side effects and health considerations
- Confirm that the WPATH criteria for care are met
- Confirm psychosocial readiness including readiness of family, school environment, etc.
- Confirm the plan for ongoing care and support
Regardless of whether treatment is started, the clinician should provide recommendations, including what education, support, further assessment or treatment can be provided.
Sometimes the clinician who completed the readiness assessment is also able to prescribe treatment. Other times, the readiness assessor will write a letter of recommendation for treatment to a primary care provider or specialist who will provide treatment and care. Sometimes clinicians work in teams with different members of the team holding different roles in the care.
Criteria for prescription
The criteria for the prescription of puberty blockers includes:
- A diagnosis of persistent well-documented gender dysphoria or gender incongruence. This can be completed by health care providers with specific training in this area including some pediatricians, family physicians, nurse practitioners, psychiatrists or psychologists.
- A review of all medical, psychological and social issues. Co-existing conditions must be deemed sufficiently stable by the health care provider in order to start puberty blockers.
- The potential risks, complications and benefits of the treatment should be discussed in detail.
- Consent must be obtained and the use of puberty blockers must be deemed in the best interest of the child or adolescent by the health care provider. Some adolescents have the capacity to provide consent to their own treatment. The involvement of the parent, guardians and caregiver in providing consent is encouraged and preferred but is not absolutely necessary under most Infant Act.
Effects of puberty blockers
If a youth was assigned male at birth, puberty blockers will stop or limit:
- Growth of facial and body hair
- Deepening of the voice
- Broadening of the shoulders
- Growth of Adam’s apple
- Growth of gonads (testes) and erectile tissue (penis)
- Growth in height
- Development of sex drive
- Accumulation of calcium in the bones
- Fertility potential
If a youth was assigned female at birth, puberty blockers will stop or limit:
- Breast tissue development
- Broadening of the hips
- Monthly bleeding
- Growth in height
- Development of sex drive
- Accumulation of calcium in the bones
- Fertility potential
Risks of taking puberty blockers
Puberty blockers are considered to be very safe overall.
Sex hormones play an important role in increasing bone density during puberty. Puberty blockers can impact bone density by either maintaining it at the current level (instead of the typical increase seen with sex hormones) or causing a slight decrease. However, bone density generally returns to the normal range after discontinuing puberty blockers and reintroducing exposure to sex hormones, either through natural body production or hormone therapy. To support bone health in youths undergoing puberty blocker treatment, vitamin D, calcium supplements, and weight-bearing exercises are recommended.
There are some important considerations related to future gender-affirming surgeries. For example, if a young person has a penis and thinks they might eventually want to have surgery to create a vagina in the future, they should talk with their primary care provider or endocrinologist. If they start taking puberty blockers early in puberty, they may need to consider an alternative surgical technique for them to have vaginoplasty surgery later as an adult.
Risks of withholding puberty blockers
Withholding puberty blockers is not a neutral option. Health care providers who refuse to provide puberty blockers to youth can cause additional distress leading to an increased risk of mental health issues. Denying someone puberty blockers causes them to experience the irreversible changes associated with puberty and ultimately ensures they develop secondary sex characteristics that are inconsistent with their gender. Overall, research indicates puberty blockers are safe and effective in supporting wellbeing, reducing distress, and providing more time for trans youth to make decisions about gender-affirming care.