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.
To really understand how these blockers work, you'll have to remember how puberty gets started. (Hint: It's all about the pituitary gland.)
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.
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.
The effect of blockers is only temporary, so the major physical changes that happen during puberty will resume once the treatment is stopped.
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.
One thing is for sure, the medications don't come cheap.
"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:
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.