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What to know about puberty blockers

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As England’s National Health Service has decided to stop prescribing puberty blockers to minors with gender dysphoria or gender incongruence, many people are asking what those are and why they’re such a hot-button issue.

“Puberty blockers are sort of like a man-made hormone analogue, and basically what they do is fool the brain into not sending messages to the ovaries and testes to secrete hormones,” said Dr. Michelle Forcier, a professor of pediatrics at the Warren Alpert Medical School of Brown University in Rhode Island, who has specialized in gender, sexual and reproductive health for 25 years.

“The brain thinks it’s got enough hormones and doesn’t message the ovaries and testes to get to work,” added Forcier, also a clinician at Folx Health. “And so, the ovaries and testes kind of just rest or go to sleep until the brain gland wakes up again and tells them, ‘Time to secrete hormones.’”

Pausing puberty for people assigned male at birth, the medications can temporarily prevent shoulders broadening, voices deepening, facial hair growing or the testes or penis enlarging, Forcier said. For those assigned female at birth, puberty blockers pause the development of breasts, wider hips or a menstrual period.

This state of limbo gives adolescents time to think about their gender identity and their guardians time to consider options before their bodies begin changing in ways that can “create massive dysphoria, depression, suicidality and a whole bunch of other poor health outcomes,” Forcier said.

The blockers “prevent permanent changes that we can’t necessarily fix or eradicate in the future,” she added. “We can’t go backwards, but at least everything (pauses) where it is.”

In the United States, at least 121,882 children ages 6 to 17 were diagnosed with gender dysphoria from 2017 to 2021, with the rate increasing 70% from 2020 to 2021, according to data collected by Reuters and health technology company Komodo Health. Just 17,600 children from that total population started taking puberty blockers or gender-affirming hormones within that five-year period. Of those children, 27% were on puberty blockers.

Talking with a medical or mental health professional is an important step in considering puberty blockers for children, experts said. - SeventyFour/iStockphoto/Getty Images
Talking with a medical or mental health professional is an important step in considering puberty blockers for children, experts said. - SeventyFour/iStockphoto/Getty Images

But changing the accessibility of these medications worldwide — including in at least 22 US states — is the fact that “gender-affirming medical care has become a highly politicized issue,” said Dr. Melina Wald, a clinical psychologist at her private practice Bespoke Health in Connecticut and New York state, via email. Wald cofounded Columbia University Medical Center’s Gender and Sexuality Program.

Here’s what else you should know about puberty blockers and, if you’re a parent, whether they’re something your child needs.

How do I know if my child needs puberty blockers?

If your kid expresses that they’re transgender or another diverse gender identity, you need to discuss with them what their identity and expression means to them, Forcier said.

Not every gender diverse child feels the need for puberty blockers, said Dr. Lauren Wilson, a pediatric hospitalist and president of the Montana chapter of the American Academy of Pediatrics, via email.

But “if a kid is freaking out about puberty or has huge behavioral, emotional or social changes before or with the changes of puberty, that’s a key to check in,” Forcier said. This distress is a main factor in whether they qualify for access, she said. Parents should ask them if there’s anything they’re nervous or excited about, or if they would like to speak with a professional.

“Ideally, parents who are considering puberty blockers for their child are working with qualified mental health professionals with significant experience in counseling families around the decision to use puberty blockers,” said Wald, who’s also on voluntary faculty at Columbia University as an assistant professor of medical psychology. “The decision is not one that is ever made lightly, and often occurs in the context of years of a relationship between a child, parents/caregivers and their doctors.”

When should someone start or stop taking puberty blockers?

These days puberty has been starting earlier, beginning in most kids around ages 8 or 10, Forcier said.

“Many kids have already completed puberty by the age of 13 or 14 … so we start blockers when puberty starts,” Forcier said. “We stop blockers when it’s appropriate or we add gender hormones to blockers when it’s appropriate.”

While puberty blockers pause puberty, gender-affirming hormones for older teens and adults help them hormonally mature into the bodily features associated with their gender identity — such as facial hair using testosterone, or a softer voice using estrogen. The appropriate time to begin could be when a kid is ready later in adolescence, when the family’s ready, or when the kid witnesses peers going through puberty, Forcier added.

Taking puberty blockers could also prevent the need for future gender-affirming surgeries, Forcier said — such as if a child assigned female at birth takes blockers, preventing the growth of breasts. That child could later transition to testosterone and never develop breasts.

“Everybody’s bodies are different, and that’s why government shouldn’t be making decisions about individual bodies,” Forcier said, “because there is not one right way to do things. The one right way to do things is to listen to the patient.”    

How safe are puberty blockers?

The NHS decision, condemned by many LGBTQ groups and some medical professionals, is based on its conclusion that after considering an evidence review it commissioned in 2020 and other information published since then, there isn’t “enough evidence to support the safety or clinical effectiveness” of puberty-suppressing hormones.

However, transgender adolescents have been using blockers for three decades, Wilson said.

They have also been used since the 1980s to treat children for whom puberty starts at an unusually early age to allow puberty to begin later. The blockers have been proven to be highly safe and effective, Wilson and Wald said.

“In adults, they can (also) be used to treat prostate cancer, endometriosis and polycystic ovarian syndrome, among other things,” Wilson said.

What are the risks of puberty blockers?

“The use of puberty blockers in any child or adolescent is associated with a risk of decrease in bone density, because bone mineralization increases with puberty hormones,” Wilson said. “But when the medication is stopped and puberty resumes or other hormone treatments are started, bone mineralization normalizes.”

Another reason not to be alarmed about the bone risk is that for any human there are multiple factors that play into bone loss or osteoporosis later in life, such as genetics, health conditions and lifestyle factors such as diet and exercise, Forcier said.

The lack of bone accretion in adolescent years due to medication is important to think about, she added, but so are the potential harms of going without puberty blockers and living in a body at odds with one’s gender.

There’s also the risk of infertility if children go straight from puberty blockers to hormone therapy, experts said.

Some people worry that children who take puberty blockers may change their minds about their gender identity later in life. But several studies have shown that most people who opt for gender-affirming care don’t later regret their choices — including an October 2022 study in Amsterdam, Netherlands, that found 98% of transgender youth who had started gender-affirming medical treatment in adolescence continued to use those hormones around five or six years later in adulthood.

“I meet with some of the older folks that have thought about gender, and they knew they had the same feelings at these younger ages,” Forcier said, challenging the notion that kids don’t know themselves. “They just didn’t have a means to do anything about it, or they were so scared or discouraged.”

There are ongoing, long-term studies of puberty blockers for transgender youth, Wilson said.

“Medications always have risks and benefits,” she added, “and good decision-making is based on accurate information and the needs of the child, first and foremost.”

CNN’s Tara John contributed to this report.

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