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Here's The Deal With Puberty Blockers

Puberty-blocking medications are being used to essentially press pause on puberty for young trans-identified patients. So how do they work?

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Since gender-nonconforming and trans children are now questioning their gender identities at earlier and earlier ages, puberty blockers have become one of the first steps many take toward potentially transitioning.

When someone makes the decision to transition, part of that process can be social (changing pronouns, letting people know what name you prefer, or trying out a new wardrobe) and, for some, it can also involve medical interventions (surgery or hormone therapy). While medical interventions may not be part of everyone's journey, for those who include it, it's often considered medically necessary.

Puberty blockers, which are commonly used to treat children who begin puberty too early, are a relatively new practice when it comes to treating trans and gender-nonconforming children. Understandably, people still have a lot of questions and concerns about using them.

BuzzFeed LGBT spoke with experts Dr. Jeremi M. Carswell, the director of the Gender Management Service Division of Endocrinology at the Children's Hospital of Boston, Dr. Ralph Vetters, medical director of the Sidney Borum Health Center at Fenway Health in Boston, Dr. Aron Janssen, founder and clinical director or the Gender and Sexuality Service at NYU's Child Study Center, and Dr. Karin Selva, a pediatric endocrinologist at Randall Children's Hospital at Legacy Emanuel in Portland, Oregon, to cut through the misconceptions and get down to the facts.

Puberty blockers (also called puberty inhibitors or puberty suppressors) are a type of medication that essentially hit pause on the physical changes that would occur during puberty.

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"It’s a great way to stop the development of unwanted secondary sexual characteristics in a trans-identified youth until they get old enough to [start transitioning]," says Vetters. Secondary sex characteristics are all those physical changes you notice popping up during puberty — growth of hair in some places, the development of breasts, a deepening of the voice, etc.

Most children who experience gender dysphoria will not continue to experience it into adolescence, but a portion do continue to experience those uncomfortable feelings and seek transitioning later in life, found one one study. By using blockers, kids are given just a bit more time to figure things out without also dealing with the discomforts of gender dysphoria — which often worsens during puberty.

Attached to the base of your brain is a little pea-sized gland called the pituitary. It's this gland that sends signaling hormones to your ovaries or testes so they can begin producing estrogen or testosterone — the sex hormones that get puberty going.

Blockers (which are classified as gonadotropin-releasing hormone analogs if you want to get fancy) work by short-circuiting the signals to the pituitary gland in the brain, says Vetters. The medication "blocks" the signaling hormones from being sent out from the pituitary, stopping the sex hormones from being produced. No signals? No puberty. And no puberty means no development of breasts, deepening of voice, or increase of facial and body hair.

Carswell says the process works the same for any gender.

Blocking agents can be administered in two different ways — via an injection or an implant.

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Lupron is an injectable medication that can be given on a monthly or trimonthly basis, explains Selva. The intramuscular injections would be given in a doctor's office by trained staff, not at home by a patient or parent.

(Here's short video of a patient being given an injection, shared with their permission, if you're feeling curious.)

Surellin or Histrelin are two medications that can be delivered via a tiny implant. The small device, placed under the skin of the patient's upper arm, releases medication over a period of one year, says Selva. The implant is replaced every year.

"The insertion site is so small, they don't use stitches to close it, only a medical glue or derma bond."

The best time to start puberty blockers is along with the very first signs of puberty — usually in the ballpark of 14 or 15 years old.

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By starting treatment with the first signs of puberty, doctors can ensure the endocrine system is working properly while stopping the complete development of unwanted secondary sexual characteristics that could cause dysphoria later, says Vetters.

If puberty has already caused the complete development of secondary sexual characteristics it's too late to "block" them, as the job has already been done. "We can never 'reverse' what has already occurred, like facial hair, or deep voice, or breasts," explains Carswell. In this case, the best option would be to consider starting hormone replacement therapy.

Once a patient begins blockers, the average time to stay on the treatment is around four to five years. "Just long enough to get a kid to the point where we can start HRT to support the development of preferred gender characteristics," explains Vetters.

The effect of blockers is only temporary, so the major physical changes that happen during puberty will resume once the treatment is stopped.

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So when a child is taken off blockers, puberty readily continues wherever it left off, explains Vetters.

So, how are blockers different from hormone replacement therapy?

Hormone replacement therapy, or HRT, is the addition of hormones that the body does not readily produce. HRT in transgender patients is started when a patient decides to begin physically transitioning — developing secondary sex characteristics that match one's gender identity.

"Sometimes people are on puberty blockers or hormone blockers and [HRT] all at the same time," says Vetters. "But it is only testosterone and estradiol [the hormones administered during HRT] that will actually cause the changes in the body that masculinize or feminize the patient."

The study of trans and gender-nonconforming children hasn't been a priority in the past, making research-based data hard to come by — but the current consensus is that blockers are safe and their effects totally reversible.

The likely immediate side effects are local, such as bleeding or infection at the implant site, says Carswell. But there are things we still don't know much about, like long-term effects on bone health or effect on brain development.

"We have some concerns about bone density – and we will watch that fairly closely," says Vetters. "We don’t generally like kids to be on puberty blockers for more than four or five years."

And because going through the "wrong puberty" can have clear long-term negative mental health effects for transgender youth, medical interventions like blockers can be, quite seriously, life-saving.

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"Transitioning is a complex process, but at its core, it is a process defined by allowing one’s internal experience of gender to be expressed and affirmed," Janssen says.

With blockers, children are given the immediate relief of knowing there is a pause placed on the physical changes of puberty, adds Janssen. When children are allowed to transition, along with the support of parents or family, improvement in mental health and functioning usually follow.

"I’ve had patients be able to go from being on four different psychiatric medications to none as a result of a successful transition,"Janssen says. "It is not an exaggeration to say for some kids, these medications are life-saving."

"Typically Depot-Lupron costs approximately $1,500 a month, if on the monthly preparation," says Selva. "The three-month preparation is equivalent in price." Meanwhile, the Histrelin implant can be up to $15,000 (for the device itself and the procedure to implant it).

And these costs won't cover the additional blood work and doctor's visits that will coincide with treatment. Several clinics designed specifically to guide children and their families through the confusing journey of transitioning have opened up around the country.

Most insurance plans still won't cover puberty blockers for trans and gender-nonconforming children, but, according to Janssen, it's (slowly) getting better. "It’s still an uphill battle and for each prescription — it involves typically up to several hours of time with various claim forms and appeals."

If a parent wants to start their child on blockers, they'll have to schedule an appointment with an endocrinologist.

"For patients under the age of 18, most programs have a set protocol involving a physical exam, collection of medical records, baseline lab tests, a therapist's recommendation, and some time with parents and family," says Vetters.

Due to the fact that anyone using puberty blockers will be a minor, it will take parent's consent and cooperation to obtain a prescription.

The latest World Professional Organization for Transgender Standards of Care makes recommendations for mental assessments of transgender youth prior to being prescribed blockers.

For more information you can always reach out to one of the major LGBT health centers around the country. A few are listed here:

The Mazzoni Center
Callen-Lorde Community Health Center

Lyon-Martin Health Services

Puberty blockers have also been outlined for use in medical transition by the Endocrine Society and World Professional Organization for Transgender Health Standards of Care.

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