Puberty Blockers To Treat Gender Dysphoria


What Are Puberty Blockers?

“Puberty blockers” are drugs used to suppress and postpone puberty in children. The most commonly used blockers are gonadotropin-releasing hormone (GnRH) agonists, which inhibit the release of sex hormones,including testosterone and estrogen. In adults, the drugs are used to treat endometriosis and prostate cancer. In children, they are approved to treat short stature and where puberty starts abnormally early (precocious puberty). 

Puberty Blockers To Treat Gender Dysphoria In Minors

Puberty blockers prevent the development of secondary sex characteristics – male features like facial hair and deep voices and female features like breast development and menstruation. They also slow the growth of sexual organs and production of hormones. They were first used in the US in a gender clinic in 2007 and came to be widely used to treat gender dysphoria by 2013. 

The use of puberty blockers in minors with gender dysphoria to postpone the development of secondary sex characteristics is an “off label” use. There are no long term studies regarding the medical, social and psychological effects of their use in this population. Technically, puberty blockers may be discontinued and used only as a “pause in the development of secondary sex characteristics” to allow the child more time to explore their gender identity without significant irreversible medical effects.  However, as a practical matter, they are part of a single pathway to medical transition. From the beginning of their use for this purpose, nearly 100% of those who are put on them, go on to use cross sex hormones.

The Effects of Puberty Blockers

Few studies have examined the effects of puberty blockers for the treatment of gender dysphoria and none of the long term effects. The potential risks include adverse effects on bone mineralization and brain development. In addition, males who are given hormone blockers at the onset of puberty and continue on to cross sex hormones, will have a permanent “micro penis” with compromised sexual function; and because of the size of their penis will be required to use a portion of their colon or peritoneal lining around their stomach in order to fashion a “neovagina” instead of using the penis skin which is how it is done in adults. Females who transition in their teens with puberty blockers and cross sex hormones transition will be sterilized, will not have eggs to bank and will have a hysterectomy after five years of testosterone injections.

History of Use To Treat Gender Dysphoria

The off label use of puberty blockers was first introduced in the treatment of gender dysphoria in the Netherlands in the late 1990s.  At that time, the condition was referenced in the DSM as Gender Identity Disorder.  It was very rare, viewed as a fluid cognitive condition and treated with a protocol referred to as “watchful waiting” wherein the individual’s mental, psychological and social processes and family dynamics were explored including any co-morbid conditions. During this exploration, children were not socially transitioned.  

In 2004, Dr. Norman Spack began using them at Boston Children’s Hospital and in 2007 he founded the at first US clinic devoted to treating minors with gender identities disorder – (GeMS Clinic).  By 2011, Tavistock GIDS in the UK had introduced the use of puberty blockers in conjunction with the watchful waiting protocol and required the child to live with the gender they were born with.  

A. Watchful Waiting and The Dutch Model in the Netherlands

The goal of the watchful waiting model is to assist the child in reflecting on and addressing their distress and gender identification prior to adopting interventions (social and medical) that would limit their opportunities to desist, as well as impact their health and functioning.  Under the watchful waiting model, 60-80% of minors desisted by early puberty.  Puberty blockers were used only where an individual persisted with their cross sex identification into puberty and to afford them even more time to resolve the condition without having to contend with developing secondary sex characteristics aggravating their dysphoria.  

In this context, puberty blockers were viewed as a reversible pause in the onset of secondary sex characteristics used only on a very discrete group of children who had gone through extensive assessment and given ample opportunity to desist.  Where the minor did not desist on puberty blockers, they then progressed to using cross sex hormones at around 16 years old and then surgeries in young adulthood.  This is referred to as the “Dutch Model” which adhered to traditional well-established medical and ethical best practices – treatment began with the least invasive, focusing on cognitive and co-morbid processes, and only graduated to less reversible more invasive interventions as the minor had increased capacity to understand its purpose, assent to its implications, and the freedom to do so.

B. The Affirming Model in the U.S. (and elsewhere)

In 2013, Gender Identity Disorder was replaced in the DSM-V with “Gender Dysphoria” to reflect that a cross-sex gender identity was not definitionally a mental disorder, rather just the distress caused by it was. – making an implicit distinction between a gender identity and the distress that could accompany it, and tacitly acknowledging (though not directly stated) that a gender identity could be congruent or incongruent with one’s sex, even though the term “identity” is not used.  This change also removed the incongruent identity as the foci of examination, and left only the distress as suitable for exploration with the implication that the distress was the result of stigma (external and internalized). Under the DSM categorization, the distress could be directly treated, the identity could not.  

This distinction is the basis of the affirming treatment model of care for gender dysphoria – the child’s incongruent identity is affirmed and the distress relieved through social and medical interventions of which puberty blockers is part of a seamless single pathway to full gender reassignment. With these changes to the narrative as to the cause of gender dysphoria with the problem being the body and not in the mind,  treatment of dysphoria was no longer subject to established ethics for minors and converted their care into a special case – where invasive medical interventions are built into the pathway from the start. In contrast to the original Dutch Model where social transition did not occur until early puberty, under the affirming model social transition begins at the prepubescent stage in anticipation of the use of puberty blockers.

Legal Challenges

The significant health, psychological and social impact of puberty blockers as part of a single seamless pathway of medical gender reassignment, along with the lack of research on the effectiveness and their long term health risks has raised legal and ethical issues as to their use in minors with gender dysphoria. In the United Kingdom, they are considered “experimental” and several States in the use have sought to ban their use. Proponents of their use site the short term psychological improvements as outweighing the informed consent issues of the minor who likely will not have the competency to weigh the long terms impact of their use.

For a more detailed discussion of the research and evidence around puberty blockers in the UK and the ethical implications of their use, please see the posts by Professor Michael Biggs, Department of Sociology at Oxford University, and our “Overview of Bell V. Tavistock.”