Ask Dr. Julia About Puberty Blockers

By Julia Mason, MD

“My pediatrician sent us to see a pediatric endocrinologist after hearing my child was unhappy with their gender.  The endocrinologist said puberty blockers are like a pause button that gives children a chance to figure things out. Do you agree with this?” 

Puberty blockers are much more than a harmless pause. Gonadotropin releasing hormone (GnRH) agonists act on the brain to stop the release of gonadotropins which normally stimulate the gonads to produce testosterone, estrogen and progesterone. These sex hormones act on the body and brain in myriad and complicated ways. GnRH agonists were originally developed to treat hormone sensitive prostate cancer, and have been used for “chemical castration” of male sex offenders.  They are used on women with endometriosis, but not for longer than 6 months due to the significant side effects.  (A second 6-month long treatment can be tried if the patient is supplemented with estrogen and progesterone.)

99% of 12 year olds are unlikely to stick with any decision. They change their minds!  A lot.

Since 1981, GnRH agonists (“puberty blockers”) have been used in very young children with central precocious puberty. Current recommendations are to use these drugs only for girls under 6 or boys under 9. In a situation where, for example, you hold off puberty from age 6 to age 8 in a girl, puberty usually appears to resume and proceed in a normal manner when the puberty blockers are removed, with recovery of lost bone density – at least in girls. I’m not sure we can extrapolate this experience over to older kids being treated with puberty blockers as part of a gender care treatment plan. There are many reports of women who suffered long term side effects after treatment with GnRH agonists, both for precocious puberty and for endometriosis.

One of my first concerns about pediatric gender medicine developed when everybody told me that 99+% of kids (like 12 year olds) treated with puberty blockers went on to cross sex hormones and surgical treatments. This was presented as evidence that “kids just know” what gender they are and we should trust them and follow their lead.  As a pediatrician with over 25 years of experience, I know that 99% of 12 year olds are unlikely to stick with any decision. They change their minds!  A lot. This is normal. Adolescence is a time of identity formation, when youth are very focused on their peers and fitting in. 

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Despite the common claim that GnRH agonists are completely reversible, if puberty blockers are administered to a child right at the onset of puberty, their gonads will not develop and they will most likely be sterilized. Dr. Marci Bowers, perhaps the premiere gender surgeon in the United States, has noted that when a boy’s puberty is blocked prior to him experiencing an orgasm, he is unlikely to ever develop the ability to have an orgasm. A clear surgical issue for males is that if puberty blockers are started at Tanner 2 (the onset of puberty), the penis and scrotum remain quite small, and additional tissue (like a piece of colon) has to be used when creating an artificial vagina.

When we give GnRH agonists to older kids, they are not blocking puberty: they are disrupting puberty. If a girl has already started her periods, these drugs will throw her into immediate menopause, with hot flashes, brain fog, all the fun, but on an accelerated time scale. Estrogen, testosterone and progesterone act on nearly every part of the body, not just the obvious things like penile and breast growth, or development of adult pattern body hair. The sex hormones act on the brain and are essential for maturation.

Sweden’s Karolinska Hospital | Credit: Holger Ellgaard

In Sweden, they have halted the use of puberty blockers (in almost all circumstances). Sweden’s Karolinksa Hospital has reported itself to the Health and Social Care Inspectorate after multiple adverse events in youth treated with GnRH agonists, such as the development of significant osteoporosis with vertebral fractures leading to chronic pain. In the UK, the National Institute for Health and Care Excellence (NICE) published a systemic review which found that GnRH agonists lead to little or no change in gender dysphoria, mental health, body image and psychosocial functioning. In the few studies that did report change, the results could be attributable to bias or chance, or were deemed unreliable. In Finland, they are prioritizing the use of psychotherapy and limiting the use of puberty blockers due to the lack of evidence for their use.

It seems like only in North America (in the United States and Canada) are we continuing to use these powerful hormonal agents with very little concern about the possibility of misdiagnosis or adverse outcomes. 

Julia Mason is a regular writer for Genspect and has over 25 years’ experience as a paediatrician.