By Jane Latus
Amid all the manufactured noise over medical care for transgender youth, and when more than half the states have introduced anti-LGBTQ+ laws, there are three important facts to know about a common early treatment for transgender adolescents: puberty blockers.
They save lives and improve mental health.
They make transitioning markedly easier for those who choose to do so later.
And, good for worried parents to know (and contrary to accusations of child abuse): they are reversible.
Though the common word is plural, puberty “blockers” are actually just one drug, Leuprolide. It is a gonadotropin-releasing hormone agonist, which works by suppressing the release of sex hormones including estrogen and testosterone. If taken early enough in puberty, it prevents breast and genitalia development, stops facial and body hair growth, stops menstruation, and prevents voice deepening. To transgender or gender nonconforming children, the development of sex characteristics that are opposite of their identity is intensely distressing.
Hormone blockers don’t “turn” kids into the opposite gender they were assigned at birth; they put a pause on puberty, giving youths and their families time to decide whether to pursue any other steps. If blockers are stopped, natal puberty resumes.
But it’s not so much the physical result of puberty blockers that stands out to those who care for trans kids—it’s the emotional impact that’s most impressive. “I see happier kids,” says Britta Shute, APRN, family nurse practitioner at Middlesex Health.
A study published in JAMA (Journal of the American Medical Association) in February found that gender-affirming care, including puberty blockers, led to 73 percent lower odds of suicidality and percent lower odds of depression within the first 12 months.
The study’s authors advised, “Beyond the need to address antitransgender legislation, there is an additional need for medical systems and insurance providers to decrease barriers and expand access to gender-affirming care.”
Middlesex Health is doing just that. In August 2021, it expanded its Center for Gender Medicine and Wellness to include individuals under 18. The program also has more than 1,200 adult trans or gender nonconforming patients.
Every day Shute sees young people who all tell her a common story: they go to sleep hoping they’ll wake up in the morning the opposite gender. They tell her of circumstances, usually adult-imposed, when they become painfully aware of an incongruent gender identity, like gym class and other gender-aligned events.
“Kids don’t have the language to express their identity,” says Shute. They just know something is wrong.
The children Shute sees are fortunate because their parents are accepting of their child’s identity and seek care and attention by making an appointment at Middlesex.
“Parents are already supportive because they are here. They aren’t where their kids are, but they come along,” Shute says. Parents tell her they want their kids to have “normal” lives and fear they will be discriminated against. Parents are reassured, however, she says, when they learn that puberty blockers create a better mental health outcome.
Middlesex offers support groups for parents and youth, as well as directing them to groups offered by the state’s four PFlag chapters. PFLAG provides confidential peer support, education and advocacy to LGBTQ+ people, their parents, families and allies.
One common parental concern is establishing whether their child’s gender identity remains consistent. Shute says it is possible that at ages 10-12, gender identity does not remain consistent. Although this is less common than persisting identity. “The nice thing is [Leuprolide] is totally reversible,” she says.
One thing Shute (and any trans person) will tell you is certain: being trans is not a phase or a whim.
Critics of gender-affirming care have proposed a “social contagion theory”, blaming what they call increasing rates of transgender identities among youths as the result of peer pressure. A study in the August issue of Pediatrics debunked that theory and its dismissal of youths’ gender identities as “Rapid Onset Gender Disorder” as contradictory to statistics and based solely on one, unscientific, online parental survey.
When young patients come to see Shute, she says the first stop is to “ensure that every intervention we do is the right choice for that particular patient.”
She does a physical exam to assess the patient’s Tanner Stage. Tanner Staging is a classification system used to track the development of secondary sex characteristics during puberty. Shute also sometimes assesses hormone levels via blood test. Blockers can be prescribed at Tanner Stage 2.
Shute uses an informed consent model where she counsels patients and guardians on the risks and benefits—the knowns and unknowns—of any medications used. Fertility, for example, is a concern. Research on this is in its early stages, Shute says, on means to preserve gametes.
Patients must also consult with a behavioral health professional, both to be sure the patient is on the right treatment plan and to ensure the patient has support.
The age of puberty onset is highly variable, says Shute, but typically 10-11 years. The youngest patient she prescribed blockers to was 9 but beyond Tanner Stage 2.
The blocker is typically injected into muscle. Depending on the formulation, a shot is repeated every 3 or 4 months. It is also available as an implant that lasts a year or more, and hormone levels are monitored at regular intervals.
What happens next? Shute sees those “happier kids” she mentioned.
“It’s incredibly freeing for these kids to start puberty blockers. It’s a little puzzling because it doesn’t often meet their goals for secondary sex characteristics, but still markedly improves their quality of life.” Another result is future adults who don’t need reversal procedures like surgery, tracheal shaves and electrolysis. Middlesex Health’s Center for Gender Medicine and Wellness employs a comprehensive, multi-disciplinary approach. Depending on their needs, a patient’s medical team might include a primary care doctor, endocrinologist, voice therapist, mental health professional, physical therapist, surgeon and more. The Human Rights Campaign has awarded Middlesex Health five consecutive “LGBTQ Healthcare Equality Leader” designations.