Puberty blockers for gender affirmation

Puberty blockers, often used for treating precocious puberty, can be used as part of providing gender-affirming care to gender-diverse youth and young adults.

Puberty blockers are medications that halt the production of estrogen or testosterone, hormones that play a role in the development of secondary sex characteristics. Secondary sex characteristics are the features that develop and appear during puberty, such as breasts, the widening of hips, facial hair, body hair, larynx enlargement (appearance of Adam’s apple) and more. For transgender youth and young adults, puberty blockers may be part of a gender-affirming treatment plan. What are puberty blockers and how can they help gender diverse and transgender patients?

What are puberty blockers?

Puberty blockers are a class of medicines called gonadotropin-releasing hormone agonists (GnRH agonists). They are approved by the U.S. Food and Drug Administration (FDA) for use in treating precocious puberty. When prescribed to treat transgender patients, the use is considered off-label. According to the American Academy of Pediatrics (AAP), off-label use of medications does not imply the use is inappropriate, illegal or should not be used; it only refers to the Food and Drug Administration’s process. Puberty blockers medications can be given as shots at one-, three- or six-month intervals. An implant that lasts for about a year also can be prescribed. All types of puberty blockers work to pause pubertal development and are completely reversible. If puberty blocking medications are stopped, puberty resumes.

What do puberty blockers do?

During puberty, gonadotropin-releasing hormone promotes the production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) in the pituitary gland. LH and FSH increase estrogen production in the ovaries, which causes breast development and eventually monthly periods for individuals assigned female at birth. LH and FSH prompt the testes to make testosterone, which causes body and facial hair, deepening of voice, increase in testes and penis size, and Adam’s apple for individuals assigned male at birth. Puberty blocker medicines suppress the production of LH and FSH, so gender-diverse and transgender youth do not develop the secondary sex characteristics of their assigned gender at birth.

Norton Children’s Endocrinology, affiliated with the UofL School of Medicine

The Pediatric and Adolescent Gender Education (PAGE) program provides gender-affirming care for children, teens and young adults whose gender identity is different from their sex at birth (transgender) and those who don’t identify with the traditional definitions of male or female (gender-diverse).

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At what age can you start hormone therapy?

For parents of gender-diverse and transgender children, it may make sense to start puberty blockers at the onset of puberty to help prevent the stress and negative feelings their child may experience due to the development of these secondary sex characteristics. Puberty blockers also allow for additional time to explore gender without the further development of secondary sex characteristics. However, the Endocrine Society’s 2017 guidelines do not recommend that gender-affirming hormone treatment with puberty blockers begin before puberty.

“For youth seeking gender-affirming care, puberty blockers are a treatment that can begin, at the earliest, after a child has signs of puberty, such as chest budding or the enlargement of the testes,” said Suzanne E. Kingery, M.D., pediatric endocrinologist with Norton Children’s Endocrinology, affiliated with the UofL School of Medicine. Dr. Kingery serves as director of the Pediatric and Adolescent Gender Education (PAGE) program.

“Before starting any kind of hormone therapy, gender-diverse and transgender children need behavioral health evaluation to assess gender dysphoria. Additionally, these children and families need education and support regarding all options for care,” Dr. Kingery said. “The PAGE program offers children and families the mental and medical care and support these children need.”

PAGE connects gender-diverse and transgender youth with pediatric endocrinologists, nurses, behavioral and mental health specialists and social workers. These professionals meet their patients’ unique needs through personalized, gender-affirming care plans. PAGE provides care based on the latest research that is consistent with guidelines outlined by the Endocrine Society and the World Professional Association for Transgender Health (WPATH).

Benefits of gender-affirming hormone therapy

Transgender children are more at risk for depression, anxiety, suicidal thoughts and suicide attempts than their non-transgender peers, according to researchers. There is a growing body of research showing that social gender affirmationand endocrinology care with puberty blockers may improve the mental health of transgender youth. A 2020 study showed that there are lower odds of lifetime suicidal ideation for transgender adults who wanted puberty blockers and had access to the care. Another 2020 study in the Journal of Adolescent Health showed that transgender youth receiving puberty blockers had fewer behavioral and emotional issues than transgender youth recently referred for care.

Additionally, as puberty blockers pause the development of secondary sex characteristics, youth who take them before gender-affirming hormones may be able to avoid future gender-affirming procedures such as mastectomies or facial feminization surgeries. A 2014 study in the journal Pediatrics showed that among 55 young transgender adults who received puberty blockers, gender-affirming hormones and gender-confirmation surgeries were able to improve their gender dysphoria. Those study participants showed overall well-being that researchers said was comparable to their peers.

How to get help

For gender-diverse youth and their parents, talking to your pediatrician can be a first step to get access to gender-affirming support and care. Additionally, young people and parents can self-refer to a program such as PAGE, which provides access to a care team that can come up with a unique, comprehensive care plan that meets your child’s short- and long-term goals for their gender-affirming care.


Norton Children’s Endocrinology

Our board-certified pediatric endocrinologists create personalized treatment plans that match the needs of each child to help them live life to the fullest.
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