Puberty blockers

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 A group of medications for youth that temporarily suppress or inhibit puberty by suppressing the production of sex hormones and preventing development of secondary sex characteristics. are medications that suppress the sex hormones Hormones, such as estrogen and testosterone, that affect sexual and reproductive development or function. 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:

1. The idea or reality of developing secondary sex characteristics Physical traits that develop after sexual maturity (puberty), such as facial hair growth, deepening of the voice or breast development. that do not fit with their gender can be very distressing. Puberty blockers can help alleviate this distress. 
2. 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.
3. Preventing unwanted physical changes can eliminate the need for some surgeries and procedures later on, such as chest construction A gender-affirming, upper surgery that removes breast tissue and sculpts remaining tissue into a shape that is typically considered to be more masculine. 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 Processes through which a health care system cares for and supports an individual while recognizing and acknowledging their gender and expression. . 

Puberty blockers are often prescribed by a pediatric endocrinologist A doctor specially trained in the study of hormones and their actions and disorders in the body. . 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 the 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 Process that a person, their health care providers, family and other supporters undertake in planning to reach their gender-affirming care goals. steps (such as a readiness assessment An evaluation conducted by a health care professional to determine if a patient is ready to begin hormone therapy or have gender-affirming surgery. ), it's important to begin the process as early as possible.

Puberty blocker funding

The puberty blocker used most often in B.C. is called Lupron Depot, which is given through a monthly injection in the thigh. It can be administered in a three-month formulation. Lupron Depot is quite expensive (approximately $400 per month) but is covered by BC PharmaCare BC government program that helps residents with the cost of eligible prescription drugs and medical supplies. . In some cases, families have the cost covered by PharmaCare Plan G. Some extended health care plans may also cover the cost of this medication.

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 World Professional Association for Transgender Health (WPATH) is a professional organization devoted to transgender health, whose mission as an international multidisciplinary professional association is to promote evidence-based care, education, research, advocacy, public policy and respect in transgender health. 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 A person’s main health care provider in non-emergency situations such as check-ups and referrals. Family doctors, general practitioners (GPs) and nurse practitioners (NPs) are all primary care providers. 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:

1. A diagnosis of persistent well-documented gender dysphoria Distress resulting from a difference between a person’s gender and their sex assigned at birth, associated gender role, and/or primary and secondary sex characteristics. (Source: WPATH) or gender incongruence A mismatch between a person's gender and the sex they were assigned at birth. . This can be completed by health care providers with specific training in this area including some pediatricians, family physicians, nurse practitioners, psychiatrists or psychologists.  
2. 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.
3. The potential risks, complications and benefits of the treatment should be discussed in detail.
4. 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 the BC 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 Tissue that is capable of stiffening or engorging with blood, which typically occurs during sexual arousal. (penis An erogenous and erectile organ located between the legs that consists of spongy tissue that can fill up with blood and may become firmer with sexual arousal. It is also a means for urination. A person may be born with a penis or have one surgically created. When referring to genitals, the Trans Care BC website uses "erogenous tissue (penis)" for trans people assigned male at birth (AMAB) and "penis" for trans people assigned female at birth (AFAB), but there are many different terms that individuals may use. )
• 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 Menstrual bleeding or period.
• 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 An internal organ located between the legs. A person may be born with a vagina or have one surgically created. When referring to genitals, the Trans Care BC website uses "internal genitals (vagina)" for trans people assigned female at birth (AFAB), and "vagina" or "vagina with vaginoplasty" for trans people assigned male at birth (AMAB), but there are many different terms that individuals may use. 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 A gender-affirming genital surgery to create a vulva (including mons, labia, clitoris and urethral opening) and vagina. 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.

Needle phobia

It is not uncommon for children and adults to have a fear of needles, which can be difficult for children and youth who are prescribed puberty blockers or injectable hormones. BC Children’s Hospital has created a resource for children and youth with needle phobia. There is also a needle phobia program at BC Children’s Hospital through Psychology services.