What are puberty blockers? What is gender affirming care?

All the information you need to fight misinformation

What is gender affirming care? What are puberty blockers? With so much misinformation out there, I wanted to speak to the experts. I feel like the discussion around so-called ‘transgender healthcare’ has been dominated by people who get all of their information from Twitter trolls. What do we really need to know about puberty blockers?

I wanted to provide an explainer that was really thorough and evidence-based - so I got an A-Team of experts. Jennifer Shields is the president of the Professional Association for Transgender Health Aotearoa, and Julia de Bres is a senior lecturer at Massey University and author of Storm Clouds and Rainbows, a resource for parents of trans kids in Aotearoa. They know what they’re talking about. 

So let’s go!

Let’s start with the basics. What are puberty blockers?

The scientific name for puberty blockers is Gonadotropin-releasing hormone analogues (GnRHa). They’re a medication that is used to pause the physical changes of puberty.

Why might a child need puberty blockers?

Puberty blockers have been used since the 1980s to treat precocious puberty in children. Precocious puberty is when children's bodies begin to change into adult bodies earlier than expected. Since the 1990s, they’ve also been used for transgender (trans) young people.

The physical changes of puberty can cause distress for trans young people. Puberty blockers give them time to consider their gender before making decisions about what’s best and right for them - whether to come off puberty blockers and resume the puberty of their sex presumed at birth, or to eventually move on to hormone therapy. Puberty blockers allow the young person and their whānau to make an informed choice either way.

Read more: My child went on puberty blockers, then they changed their mind

Puberty blockers are reversible. Young people can stop taking them at any time and puberty will recommence.

Photo by Aedrian

What is the process for getting puberty blockers for your child?

Most people will start by going to their GP. Most GPs have access to good resources and referral pathways now that give lots of general information.

In some parts of the country, a young person and their family can go to a specialised youth service. Such services aim to get to know the young person as a whole and to understand their gender journey and goals, via a series of connections and appointments. Ideally, this will involve a multidisciplinary team, with each young person and family seen by a specialist adolescent health physician alongside a nurse or social worker. These health practitioners are trained in child and adolescent development, physical and mental health, as well as having knowledge about medications. A psychologist is involved as part of the team review and can meet with families when needed.

In other parts of the country, it is paediatricians, paediatric endocrinologists or GPs with a special interest in gender-affirming care who prescribe blockers. They usually do that collaboratively with a mental health professional specialising in working with young people who is involved in the assessment process and looks at supports that might be needed.

Why is there a lot of frothing about puberty blockers in Aotearoa now?

Puberty blockers have been used in Aotearoa by healthcare teams with specialist knowledge around gender-affirming care for over 10 years, and since the 80s for precocious puberty. Their practice is informed by international evidence-based guidelines, however, puberty blockers (and gender affirming care more broadly) are under a lot of attention from disinformation networks, especially overseas, and that’s been imported here to Aotearoa. Internationally, puberty blockers have been used as a wedge issue - a way to work towards banning gender affirming care for everyone, not just young people.

Photo by U. Storsberg

What is the Cass Review?

A few months ago we saw the Cass Review in England make the news. The Cass Review is a controversial re-evaluation of England’s models of providing gender-affirming healthcare for children and young people. It was commissioned by the NHS in 2019 and examines England’s approach of providing this care through a centralised clinic model, with wait times for the service stretching to many years. The anti-trans lobby in the UK have used the review to push to restrict young people’s access to gender affirming care, rather than to improve the care that trans young people need.

Didn't the Cass Review have some major issues?

A new report from the Yale Law School, Yale Medical School, and the Integrity Project (based at Yale Law) was released last week. It examined the Cass Review, its processes and its findings, and found it was critically flawed.

The report is well worth reading - its authors collectively have 86 years of experience in caring for nearly 5000 trans young people, and have published 168 peer-reviewed studies in the field of gender-affirming care.

The review of The Cass Review found -

• The Cass Review did not call for a ban on gender-affirming care, and should not be cited in support of bans,

• The "low quality evidence" argument in Cass is flawed, pseudoscientific, and subjective, and

• The Cass Review misrepresents and misinterprets its own data.

You can read more about that here: New Yale Law report finds Cass Review critically flawed.

The Cass review claimed that there wasn’t enough evidence to show the benefits of puberty blockers, hormone therapy, and social transition - things like changing names, pronouns, and clothing. It recommended against providing gender affirming care, and even against letting young people socially transition.

Unfortunately, the Cass review ignored lots of evidence in support of gender affirming care - in one of their systematic reviews, they threw out 101 studies from a total of 103. No trans people or clinicians experienced in providing gender affirming care were involved in the review’s advisory group or in the review’s conclusions or recommendations. In contrast, people who have actively advocated against access to gender affirming care and supported conversion practices for trans people fed into the review. Trans young people who participated in the Cass Review have shared their disappointment that the final report ignored the overwhelmingly positive experiences they had shared about being on puberty blockers. Since the Cass review was published, Dr Cass walked back a number of these recommendations, saying in an interview that both blockers and hormones should be available to trans young people as part of an individual care plan, and recommending the kind of approach to gender affirming care we have in Aotearoa.

Photo by NCI

So, are there risks to using puberty blockers?

All medicines have risks and benefits - in medicine, how healthcare professionals explain these to us, along with all our options and ways to reduce the risks, is a process called informed consent. This is something that happens all the time with medications used for everything from blood pressure to diabetes to mental health.

The side effects of puberty blockers are very rare in the short term. One study showed a very small number of young people decided to stop taking puberty blockers due to symptoms including migraines, nausea and hot flushes. Other data, including from their long-term use for precocious puberty, suggest that puberty blockers are as safe as any other medical care. A common concern that is raised is their potential effects on bone density. Adolescence is usually a time of increasing bone density and while young people are on blockers their bone density is likely not to build up as much as it would usually do.  This is unlikely to be a problem at the time, and will likely improve when these young people stop blockers or go onto gender-affirming hormones.  This is one of the reasons young people don’t stay on blockers for too long - and why clinicians encourage them to focus on other ways to promote their long term bone health, like exercise, calcium, and vitamin D - things that are good for every teenager.

Why are some places banning or restricting blockers if side effects are so rare?

Great question! Most places that have restricted access to blockers - like England and some states in the USA - have done so because of this idea that there's not enough evidence about their use for trans young people. This is more disinformation from these coordinated campaigns, and thankfully, people are starting to see through this argument! Last month, a federal judge overturned a gender affirming care ban in Florida. In his ruling, he made it clear that the "low quality evidence" argument has no basis - because while we have some evidence for the benefit of this care, there is no evidence of any harm.

So what next?

Sieving out misinformation about puberty blockers can seem daunting, especially for parents with a trans child. No one worries or cares more about the safety of puberty blockers than these parents do.  They are everyday people, from all backgrounds and parts of Aotearoa, who have seen the difference puberty blockers have made for their children.  Their voices, and the experiences of their children, deserve to be heard. 

The misinformation about puberty blockers is part of coordinated campaigns that have broader goals to limit the healthcare that trans people can access. What we’ve seen in the USA, for example, is that bans on gender affirming care for young people quickly turn into bans on gender affirming care for all trans people. It’s important that we don’t buy into the same scare campaign here in Aotearoa.

Puberty blockers should be subject to the same rigorous standards we apply to all our healthcare - and they already are. 

For more information on the use of puberty blockers in Aotearoa, including parent perspectives, head to Project Village Aotearoa.