Puberty blockers

Puberty blockers are medications that temporarily pause the development of physical characteristics from gonadotropin-releasing hormones (GnRH) in the body. Blockers might be taken while making a decision about beginning or waiting to be allowed to begin hormonal affirmation, or before accessing some kinds of gender affirming surgeries.

For young trans people wanting access hormonal affirmation, puberty blockers are sometimes the first step.

Puberty blockers are taken by trans people whose bodies are just about to undergo puberty. For those who are pre-pubertal, gender affirmation is only ever social. Masculinising and feminising hormones are commenced after puberty would have, or did, occur.

“They work by blocking the hormones — testosterone and estrogen — that lead to puberty-related changes in your body. This stops things like periods and breast growth, or voice-deepening and facial hair growth. “

Planned Parenthood 2

Information and resources to assist clinicians learn more about puberty blockers can be found here.

The puberty blocker that is right for you will depend on a combination of your age, puberty-stage, preferences, access, existing contraindications, and other factors. Talk to your doctor about what treatment is going to be right for you (or your child).

GnRH analogues

GnRH analogues drugs suppress the secretion of gonadotropin-releasing hormones, and are commonly used to prevent an spontaneous puberty in young trans people.

These include:

• Goserelin (Zoladex) - implant with a cycle of 10-12 weeks

• Leuprorelin (Lucrin) - injection every 3-4 months

• Triptorelin (Diphereline) - injection every 5-6 months

Puberty suppression may continue for a few years, at which time a decision is made to either discontinue all hormone therapy or transition to a feminizing/masculinizing hormone regimen. Pubertal suppression does not inevitably lead to social transition or to [further medical gender affirmation].

WPATH

Studies on puberty blockers have shown that they are an effective and safe part of the hormonal therapy toolkit for young trans people.

GnRH analogues have been used to suppress puberty for the last 20 years and short-mid term studies have found them to be well tolerated by the body when used temporarily. Long term studies are currently underway.

GnHR analogues can affect your final height and could make you slightly taller if administered without gender affirming hormones and before the first growth spurt of puberty. This is because bones do not stop growing until exposed to estrogen or testosterone.

Accessing a Paediatrician or Paediatric Endocrinologist in a timely manner is important, and a GP is the first step to coordinating care.

In Australia, trans young people may commence puberty blockers with permission from both carers or guardians, and their doctor. This is usually coordinated through a multi-disciplinary team, when available.

A Family Court ruling (Re Jamie, 20174) overturned existing law that required an adolescent and their family to go to The Family Court of Australia to gain authority to commence puberty blockers prior to 18.

This ruling was further clarified in the judgement of Re Imogen 20205 to mean that treatment can be commenced in Australia with people under 18 when there is no dispute between parents (or those with parental responsibility), the medical practitioner and the young person themselves with regard to:

• The Gillick competence of an adolescent; or

• A diagnosis of gender dysphoria; or

• Proposed treatment for gender dysphoria

Any dispute requires a mandatory application to the Family Court of Australia as per the judgement of Re Imogen 2020.

Medical practitioners seeing patients under the age of 18 are unable to initiate puberty blockers or gender affirming hormonal treatment without first ascertaining whether or not a child’s parents or legal guardians consent to the proposed treatment. If there is a dispute about consent or treatment, a doctor should not administer puberty blockers (“Stage 1”), hormones (“Stage 2”) or surgical intervention (“Stage 3”) without court authorisation.

For trans people under 18 whose parents, carers or guardians will not consent to starting hormones, the Family Court must be involved. Unfortunately, in many cases where parents, carers or guardians do not consent, this may result in a trans person simply waiting until they are 18 to access puberty blockers and hormones, or seeking to access them outside of medical care and oversight.

Further assistance for trans people is also available at Inner City Legal Centre who offer a NSW-wide free legal service for trans and gender diverse people.

AusPATH endorses local and international Standards of Care that offer guidance on puberty suppression for trans young people and adolescents.

The Australian Standards of Care for trans and gender diverse children and adolescents6 outlines the criteria for adolescents to commence puberty suppression:

1. A diagnosis of Gender Dysphoria in Adolescence, made by a mental health clinician with expertise in child and adolescent development, psychopathology and experience with children and adolescents with gender dysphoria.

   • The WPATH Standards of Care define a mental health professional as including psychologists, mental health social workers, child and adolescent mental health workers, and more. If you are unsure, it’s worth checking with your GP to see who will be the best fit.

2. Medical assessment including fertility preservation counselling has been completed by a general practitioner, paediatrician, adolescent physician or endocrinologist. This assessment should include further fertility preservation counselling by a gynaecologist and/or andrologist as required with referral for fertility preservation when requested.

3. Tanner stage 2 pubertal status has been achieved. This can be confirmed via clinical examination with presence of breast buds or increased testicular volume (>4 mL) and elevation of luteinising hormone to ≥0.5 IU/L.

4. The treating team should agree that commencement of puberty suppression is in the best interest of the adolescent and assent from the adolescent and informed consent from both their legal guardians has been obtained.

GnRH analogues are not listed on the PBS for puberty suppression related to gender affirmation, and as a result the costs can be prohibitively expensive for many young people and their families. Some young people will seek out public clinics but there are very few currently available in NSW.

For a list of doctors who support and understand trans people and our needs, check out ACON’s Gender Affirming Doctor List, available here.