Pubertal blockers for transgender and gender-diverse youth

Date Updated: 06/18/2022

Transgender and gender-diverse children might choose to temporarily suppress puberty through the use of prescription medications called pubertal blockers. But deciding to get this treatment is a big step.

The medications mostly commonly used to suppress puberty are known as gonadotropin-releasing hormone (GnRH) analogues. Here's what you need to know about the benefits, side effects and long-term effects.

What do pubertal blockers do?

Puberty's physical changes can cause intense distress for many gender-nonconforming adolescents. When taken regularly, GnRH analogues suppress the body's release of sex hormones, including testosterone and estrogen, during puberty.

Sex hormones affect:

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

In those identified as male at birth, GnRH analogues decrease the growth of facial and body hair, prevent voice deepening, and limit the growth of genitalia.

In those identified as female at birth, treatment limits or stops breast development and stops menstruation.

What are the benefits of use of pubertal blockers?

Gender dysphoria is the feeling of discomfort or distress that might accompany a difference between experienced or expressed gender and sex assigned at birth. Gender dysphoria that starts in childhood and worsens with the start of puberty rarely goes away.

For children who have gender dysphoria, suppressing puberty might:

Improve mental well-being
Reduce depression and anxiety
Improve social interactions and integration with other kids
Eliminate the need for future surgeries
Reduce thoughts or actions related to self-harm

However, puberty suppression alone might not ease gender dysphoria.

What are the criteria for use of pubertal blockers?

To begin using pubertal blockers, a child must:

Show a long-lasting and intense 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 treatment
Have entered the early stage of puberty
Provide informed consent

Particularly when a child hasn't reached the age of medical consent, parents or other caretakers or guardians must consent to the treatment and support the adolescent through the treatment process.

What happens when pubertal blockers are stopped?

Use of GnRH analogues pauses puberty, providing time to determine if a child's gender identity is long lasting. It also gives children and their families time to think about or plan for the psychological, medical, developmental, social and legal issues ahead.

If an adolescent child decides to stop taking GnRH analogues, puberty will resume and the normal progression of the physical and emotional changes of puberty will continue.

What is the typical treatment time frame?

For most children, puberty begins around ages 10 to 11, though puberty sometimes starts earlier. The effect of pubertal blockers depends on when a child begins to take the medication. GnRH analogue treatment can begin at the start of puberty to delay secondary sex characteristics. In slightly later stages of puberty, the treatment could be used to stop menstruation or erections or to prevent further development of undesired secondary sex characteristics.

While most children take the medication for a few years, every child is different. After suppressing puberty for a few years, your child might decide to stop puberty blocking therapy or pursue other hormone treatments.

How is the medication given?

GnRH analogue treatments for children are prescribed, administered and monitored by a pediatric endocrinologist. The medication is typically given as injections, either monthly or every three months, or through an implant placed under the skin of the upper arm. The implant typically needs to be replaced every 12 months.

While taking pubertal blockers, your child will have regular blood tests to monitor the medication's effectiveness. Your child will also be monitored for any side effects.

What are the possible side effects and complications?

It's important for your child to stay on schedule with all related medical appointments. Contact your child's doctor if any changes cause you or your child concern.

Possible side effects of GnRH analogue treatment include:

Injection site swelling
Weight gain
Hot flashes
Headaches

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

Growth spurts
Bone growth and density
Future fertility — depending on when pubertal blockers are started

Children may have their height checked every three months. Bone density is also checked periodically. If bone growth or density is a concern, your child's health care provider might prescribe a different medication, stop treatment with GnRH analogues or recommend the best time to start cross-hormone therapy.

If children with male genitalia begin using GnRH analogues early in puberty, they might not develop enough penile and scrotal skin for certain gender affirming genital surgical procedures, such as penile inversion vaginoplasty. Alternative techniques, however, are available.

In addition, delaying puberty beyond one's peers can be stressful. Your child might experience lower self-esteem.

What other treatments are needed?

Assessment and counseling by a behavioral health provider can help you and your child as you move through the decision-making process and provide support during therapy. Engaging your child's schoolteachers and officials also might help ease your child's social adjustment during this process.

After a period of adjusting to pubertal blockers, adolescents might work with their care team to add cross-hormone treatment. This is done to develop masculine or feminine secondary sex characteristics, helping the mind and body look and act like the gender with which your child identifies. Keep in mind that some of these changes aren't reversible or will require surgery to reverse the effects.

GnRH analogues aren't the only medications that can delay puberty. If you're interested in alternative treatments, talk to your child's doctor.