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Puberty blockers (also called puberty inhibitors or hormone blockers) are medicines used to postpone puberty in children. The most commonly used puberty blockers are gonadotropin-releasing hormone (GnRH) agonists, which suppress the production of sex hormones, including testosterone and estrogen. In addition to their use in treating precocious puberty, which involves puberty occurring at an unusually early age (and sometimes idiopathic short stature) in children, puberty blockers are also used for transgender children to delay the development of unwanted sex characteristics, so as to allow transgender youth more time to explore their gender identity.

While few studies have examined the effects of puberty blockers for gender non-conforming and transgender adolescents, the studies that have been conducted generally indicate that these treatments are reasonably safe, are reversible, and can improve psychological well-being in these individuals, including reducing suicidality.

The use of puberty blockers in transgender youth is supported by the Endocrine Society and the World Professional Association for Transgender Health (WPATH)

At least 18 US states have banned elements of gender affirming care for transgender youth including puberty blockers. Some of these state laws include criminal penalties for doctors that provide puberty blockers to their patients.

Medical uses

Delaying or temporarily suspending puberty is a medical treatment for children whose puberty started abnormally early (precocious puberty). Puberty blockers have been used on-label since the 1980s to treat precocious puberty in children, and were approved for use in treating precocious puberty in children by the U.S. Food and Drug Administration (FDA) in 1993. Puberty blockers are also commonly used for children with idiopathic short stature, for whom these medications can be used to promote development of long bones and increase adult height. In adults, the same drugs have a range of different medical uses, including the treatment of endometriosis, breast and prostate cancer, and polycystic ovary syndrome.

Puberty blockers prevent the development of biological secondary sex characteristics.

Gender-affirming care

Puberty blockers are sometimes prescribed to young transgender people, to temporarily halt the development of secondary sex characteristics. Puberty blockers allow patients more time to solidify their gender identity, without developing secondary sex characteristics, and give transgender youth a smoother transition into their desired gender identity as an adult. If a child later decides not to transition to another gender the medication can be stopped, allowing puberty to proceed. Little is known about the long-term side effects of hormone or puberty blockers in children with gender dysphoria. Although puberty blockers are known to be safe and physically reversible treatment if stopped in the short term, it is also not known whether hormone blockers affect the development of factors like bone mineral density, brain development and fertility in transgender patients.

Puberty blockers have not received FDA approval for use on children who are transgender. The practice of off-label prescription is common in children's medicine, and does not indicate an improper, illegal, or experimental use of medicine. According to pediatric endocrinology expert Brad Miller, pharmaceutical companies that make puberty blocker drugs for children with gender dysphoria have refused to submit them for FDA approval because doing so would cost too much money and "because (transgender treatment) was a political hot potato."

While few studies have examined the effects of puberty blockers for gender non-conforming and transgender adolescents, the studies that have been conducted generally indicate that these treatments are reasonably safe, are reversible, and can improve psychological well-being in these individuals. A 2020 review published in Child and Adolescent Mental Health found that puberty blockers are associated with such positive outcomes as decreased suicidality in adulthood, improved affect and psychological functioning, and improved social life. A 2022 review published in the Annual Review of Medicine found clearly beneficial, lifesaving impacts of puberty blockers on a scale of up to six years, but found research lacking beyond that time frame. The World Professional Association for Transgender Health's Standards of Care 8, published in 2022, found puberty-blocking medication to be "medically necessary" and recommends them for usage in transgender adolescents once the patient has reached Tanner stage 2 of development, and state that longitudinal data shows improved outcomes for transgender patients who receive them.

A 2020 commissioned review published by the UK's National Institute for Health and Care Excellence concluded that the quality of evidence for puberty blocker outcomes (for mental health, quality of life and impact on gender dysphoria) was of very low certainty based on a modified GRADE approach, but that "it is plausible, however, that a lack of difference in scores from baseline to follow-up is the effect of GnRH analogues in children and adolescents with gender dysphoria, in whom the development of secondary sexual characteristics might be expected to be associated with an increased impact on gender dysphoria, depression, anxiety, anger and distress over time without treatment." A 2024 systematic review using the same approach re-affirmed the conclusions of the NICE report, concluding that the currently available studies have "significant conceptual and methodological flaws".

The NICE review has been criticized by WPATH and EPATH for excluding studies combining puberty blockers and hormone replacement therapy and by parents of transgender youth for excluding evidence of its safety when used by cisgender youth undergoing precocious puberty. The review has also been criticized for prioritization of "high quality" evidence according to the GRADE approach, which designates randomized control trials (RCTs) as "high quality", since RCTs are widely considered unfeasible and unethical for transgender youth due to the fact those in the control group would have to be denied treatment. The review also deviated from GRADE guidance which states that "low or very low quality evidence can lead to a strong recommendation" by not taking the low-quality studies into account when forming evidence review recommendations.

The longest follow-up study followed a transgender man who began taking puberty blockers at age 13 in 1998, before later taking hormone treatments, and later got gender confirmation surgery as an adult. His health was monitored for 22 years and at age 35 in 2010 was well-functioning, in good physical health with normal metabolic, endocrine, and bone mineral density levels. There were no clinical signs of a negative impact on brain development from taking puberty blockers.

Criticism

The use of puberty blockers for gender affirming care has attracted some criticism, due primarily to the lack of randomized controlled trials within the research base. However, randomized controlled trials are not regarded as feasible or ethical in the case of research for gender-affirming care.

The Finnish government commissioned a review of the research evidence for treatment of transgender minors and the Finnish Ministry of Health concluded that there are no research-based health care methods for minors with gender dysphoria. On the other hand, along with the American Academy of Pediatrics, the Finnish Ministry supports the use of puberty blockers for minors on a case-by-case basis.

Adverse effects

Short-term side effects of puberty blockers include headaches, fatigue, insomnia, muscle aches and changes in breast tissue, mood, and weight.

Adverse effects on bone mineralization and compromised fertility are potential risks of pubertal suppression in gender dysphoric youth treated with GnRH agonists. To protect against lower bone density, doctors recommend exercise, calcium, and Vitamin D. Additionally, genital tissue in transgender women may not be optimal for potential vaginoplasty later in life due to underdevelopment of the penis.

Research on the long-term effects on brain development, cognitive function, fertility, and sexual function is limited. A 2020 study conducted by John Strang and other researchers suggested that "pubertal suppression may prevent key aspects of development during a sensitive period of brain organization", adding that "we need high-quality research to understand the impacts of this treatment – impacts which may be positive in some ways and potentially negative in others." The Endocrine Society Guidelines, while endorsing the use of puberty blockers for treatment of gender dysphoria, underscores the need for more rigorous safety and effectiveness evaluations and careful assessment of "the effects of prolonged delay of puberty in adolescents on bone health, gonadal function, and the brain (including effects on cognitive, emotional, social, and sexual development)."

In 2016, the FDA ordered drugmakers to add warning labels to puberty blocker drugs being used to treat children with precocious puberty stating: "Psychiatric events have been reported in patients", including symptoms "such as crying, irritability, impatience, anger and aggression." The warning labels were added after the FDA received reports of 10 children who had suicidal thoughts, including one attempt at suicide. One of these children, a 14-year-old, was taking a puberty blocker drug for gender dysphoria.

In 2017, it was reported that the FDA had received more than 10,000 reports of adverse events from women who took Lupron in order to grow taller.

In 2022, the FDA reported that there have been six cases of idiopathic intracranial hypertension in 5 to 12-year-old children assigned female at birth taking puberty blockers. Five who experienced the side effect were receiving treatment for precocious puberty and one who experienced the side effect was transgender and was receiving treatment for gender dysphoria. Morissa Ladinsky, a pediatrician with University of Alabama-Birmingham who works with transgender youth, said that " is an inordinately well-known side effect that can happen for many, many different medications, most commonly, oral birth control pills." Referring to the six reported side effects, Ladinsky said that "It doesn't even approach any semblance of what we call in medicine, statistical significance".

A 2024 University College London review of the impact of suppressing puberty on psychological function found some evidence of a detrimental effect on IQ, and no evidence that cognitive effects were fully reversible.

Available forms

A number of different puberty blockers are used. These include the GnRH agonists buserelin, histrelin, leuprorelin, nafarelin, and triptorelin. GnRH agonists are available and used as daily subcutaneous injections, depot subcutaneous or intramuscular injections lasting 1 to 6 months, implants lasting 12 months, and nasal sprays used multiple times per day. GnRH antagonists are also expected to be effective as puberty blockers but have not yet been widely studied or used for this purpose. Progestogens used at high doses such as medroxyprogesterone acetate and cyproterone acetate have been used as puberty blockers in the past or when GnRH agonists are not possible. They are not as effective as GnRH agonists and have more side effects. The antiandrogen bicalutamide has been used as an alternative puberty blocker in transgender girls for whom GnRH agonists were denied by insurance.

Centrally acting puberty blockers such as GnRH agonists are ineffective in peripheral precocious puberty, which is gonadotropin-independent. In this situation, direct inhibitors of sex hormone action and/or synthesis must be employed instead. Treatment options for peripheral precocious puberty in girls, such as in McCune–Albright syndrome, include ketoconazole, the aromatase inhibitors testolactone, fadrozole, anastrozole, and letrozole, and the antiestrogens tamoxifen and fulvestrant. Treatment possibilities for peripheral precocious puberty in boys, such as in familial male-limited precocious puberty, include the antiandrogens bicalutamide, spironolactone, and cyproterone acetate, ketoconazole, and the aromatase inhibitors testolactone, anastrozole, and letrozole.

In the United States, the main providers of puberty blockers are Endo International and AbbVie.

Legal and political challenges

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The prescription of puberty blockers to transgender children has been subject to misinformation and anti-transgender legislation.

Some opponents of the use of puberty blockers argue that minors are not able to give proper consent. Some advocates for the use of puberty blockers argue that there are psychological and developmental benefits of puberty blockers which are compelling enough to overlook the issue of informed consent in many cases. According to a 2019 study, a "multidisciplinary staged approach" is necessary "to ensure meaningful consent". According to the 2021 editorial, "Disproportionate emphasis is given to young people's inability to provide medical consent, a moot point given that—like any medical care—parental consent is required. ... what matters ethically is whether an individual has a good enough reason for wanting treatment". Bioethicist Maura Priest contends that, even in the absence of parental permission, the use of puberty blockers could mitigate any adverse effects on familial relationships within the home of a transgender child. She posits that there are benefits to having access to puberty blockers, while psychological costs are often associated with untreated gender dysphoria in children. Bioethicist Florence Ashley contends that counseling and educating the parents of transgender youth could also be beneficial to familial relationships.

One study found that the use of puberty blockers decreases the risk of depression and reduces behavioral issues. Opponents have argued that potentially negative "effects may be too subtle to observe during the follow-up sessions by clinical assessment alone".

Opponents of the use of puberty blockers in adolescents argue that gender identity is still fluctuating at this age and that blockers might interfere with gender identity formation and development of a free sexuality, as well as pointing to what they consider to be high rates of desistance after puberty. Opponents also argue that puberty blockers "may alter the course of gender identity development, essentially 'locking in' a gender identity that may have reconciled with biological sex during the natural course of puberty." Almost all (98%) children who took puberty blockers in a significant recent study by the main UK child/adolescent gender clinic continued on to hormone replacement therapy. Similarly, most reviews noting psychological benefits refer to the classic Dutch study, which had very stringent requirements for medical treatment.

In April 2021, Arkansas passed a ban on treatment of minors under 18 with puberty blockers, but it was temporarily blocked by a federal judge a week before the law was set to take effect. In April 2022, Alabama passed a ban from minors under 19 from obtaining puberty blockers and made it a felony for a doctor to prescribe puberty blockers to a minor with a punishment of up to ten years in prison. The Alabama law was partially blocked by a federal judge a few days after the law took effect. In August 2022, Florida banned Medicaid from covering gender affirming care, including puberty blockers.

Puberty blockers have also been banned in Utah, Idaho, Montana, North Dakota, South Dakota, Iowa, Indiana, Kentucky, Mississippi, Florida, West Virginia, Tennessee, and Oklahoma.

Some state bans on gender affirming care including puberty blockers have been declared unconstitutional. Furthermore, bans on puberty blockers have been criticized as governments interfering with the patient-doctor relationship and taking away healthcare decisions from parents and families for their children. State level bans on gender affirming care, including puberty blockers, in the United States have led some families with transgender children to move out of their states.

Stances of medical organizations

More than a dozen major American and Australian medical associations, as well as the World Professional Association for Transgender Health (WPATH), generally support puberty blockers for transgender youth and have come out against efforts to restrict their use. In Europe, however, some medical groups and countries have taken a more precautionary stance following systematic reviews of the evidence base, discouraging or limiting the use of puberty blockers.

Australia

The Royal Australasian College of Physicians, the Royal Australian College of General Practitioners, the Australian Endocrine Society, and AusPATH all support access to puberty blockers for transgender youth.

Finland

In 2020, Finland revised its guidelines to prioritise psychotherapy over medical transition, but the Council for Choices in Health Care allows the use of puberty blockers in transgender children after a case-by-case assessment if there are no medical contraindications.

France

In 2022, France's Académie Nationale de Médecine recommended the "greatest reserve" when considering puberty blockers due to potential side effects, including "impact on growth, bone weakening, risk of infertility".

Norway

In 2020, the Norwegian Directorate for Health, the governmental body that develops health guidelines, released one for gender incongruence recommending puberty blockers between Tanner stage 2 and the age of 16 following an interdisciplinary assessment, stating they were reversible and there is no reliable evidence of adverse long-term effects. In 2023, the Norwegian Healthcare Investigation Board, an independent non-governmental organization, issued a non-binding report finding "there is insufficient evidence for the use of puberty blockers and cross sex hormone treatments in young people" and recommending restrictions on such care. The Directorate stated the guidelines acknowledged the limited evidence base and their recommendations were "limited to the organisation and content of services on different treatment levels necessary to fulfil patient rights, as required by Norwegian health regulation," further stating that they planned to begin talks with clinicians and patient representatives to determine whether revisions are necessary. Misinformation that Norway had banned gender affirming care proliferated on social media.

Sweden

Sweden's Karolinska Institute, administrator of the second-largest hospital system in the country, announced in March 2021 that it would discontinue providing puberty blockers or cross-sex hormones to children under 16. Additionally, the Karolinska Institute changed its policy to cease providing puberty blockers or cross-sex hormones to teenagers 16–18, outside of approved clinical trials. On 22 February 2022, Sweden's National Board of Health and Welfare said that puberty blockers should only be used in "exceptional cases" and said that their use is backed by "uncertain science".

However, other providers in Sweden continue to provide puberty blockers, and a clinician's professional judgment determines what treatments are recommended or not recommended. Youth are able to access gender-affirming care when doctors deem it medically necessary. The treatment is not banned in Sweden and is offered as part of its national healthcare service.

United Kingdom

On 30 June 2020, the British National Health Service changed the information it displayed on its website regarding the reversibility of the effects of puberty blockers and their use in the treatment of minors with gender dysphoria. Specifically, the NHS removed language stating that puberty blockers were "fully reversible" and that "treatment can usually be stopped at any time". In its place, the NHS stated that "little is known about the long-term side effects of hormone or puberty blockers in children with gender dysphoria. Although the Gender Identity Development Service (GIDS) advises this is a physically reversible treatment if stopped, it is not known what the psychological effects may be. It's also not known whether hormone blockers affect the development of the teenage brain or children's bones. Side effects may also include hot flushes, fatigue and mood alterations."

The Bell v Tavistock decision by the High Court of Justice for England and Wales ruled children under 16 were not competent to give informed consent to puberty blockers, but this was overturned by the Court of Appeal in September 2021.

Efforts to ban puberty blockers for transgender youth are opposed by the British Medical Association. The National Health Service currently supports the use of puberty blockers for children under 16 years of age only in the context of centrally administered clinical research, and strongly discourages seeking treatment from unregulated sources.

In March 2024, NHS England announced that it would no longer prescribe puberty blockers to minors outside of use in clinical research trials, citing insufficient evidence of safety or clinical effectiveness. Children already receiving puberty blockers via NHS England will be able to continue their treatment. NHS England hopes to have a study into the use of puberty blockers in place by December 2024, with eligibility criteria yet to be decided. Children in England can still be prescribed puberty blockers through some private clinics that are not associated with NHS England.

United States

The use of puberty blockers in transgender youth is supported by:

• The American Medical Association
• The American Psychological Association
• The American Academy of Pediatrics and the Endocrine Society
• The American Academy of Child and Adolescent Psychiatry (AACAP)
• The American Psychiatric Association
• The Pediatric Endocrine Society
• The American College of Obstetricians and Gynecologists
• The American College of Physicians
• The American Academy of Family Physicians
• The American Osteopathic Association
• The American Association of Clinical Endocrinologists
• The American Nurses Association

Public opinion

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An April 2021 PBS Newshour/NPR/Marist poll with the question "Do you support or oppose legislation that would prohibit gender transition-related medical care for minors" found 66% of Americans would oppose a ban, including 69% of Democrats, 70% of Republicans, and 64% of Independents.

A February 2022 poll by LGBT support service The Trevor Project and Morning Consult found that 52 percent of American adults expressed some level of support for transgender minors having access to puberty blockers if it is recommended by their doctor and supported by their parents.

A Washington Post-KFF poll conducted in November 2022 found that 68 percent of adults oppose access to puberty-blocking medication for transgender children ages 10 to 14, and 58 percent oppose access to hormonal treatments for transgender children ages 15 to 17.

In a January 2023 Deseret News/HarrisX poll, 55 percent of Americans supported banning gender hormone therapy for transgender minors with parental or guardian approval, while 45 percent opposed such a ban.

A September 2023 poll by 19th News/SurveyMonkey found that 39 percent of American adults supported transgender minors having access to any kind of gender-affirming care, including puberty blockers, hormones, therapy, and surgery.

References

1. Hemat RA (2 March 2003). Andropathy. Urotext. pp. 120–. ISBN 978-1-903737-08-8.
2. Becker KL (2001). Principles and Practice of Endocrinology and Metabolism. Lippincott Williams & Wilkins. pp. 973–. ISBN 978-0-7817-1750-2.
3. "Pubertal blockers for transgender and gender diverse youth". Mayo Clinic. 16 August 2019. Retrieved 15 December 2020.
4. ^ Stevens J, Gomez-Lobo V, Pine-Twaddell E (December 2015). "Insurance Coverage of Puberty Blocker Therapies for Transgender Youth". Pediatrics. 136 (6): 1029–31. doi:10.1542/peds.2015-2849. PMID 26527547.
5. ^ Alegría CA (October 2016). "Gender nonconforming and transgender children/youth: Family, community, and implications for practice". Journal of the American Association of Nurse Practitioners. 28 (10): 521–527. doi:10.1002/2327-6924.12363. PMID 27031444. S2CID 22374099.
6. ^ Mahfouda S, Moore JK, Siafarikas A, Zepf FD, Lin A (October 2017). "Puberty suppression in transgender children and adolescents". The Lancet Diabetes & Endocrinology. 5 (10): 816–826. doi:10.1016/s2213-8587(17)30099-2. PMID 28546095. S2CID 10690853. The few studies that have examined the psychological effects of suppressing puberty, as the first stage before possible future commencement of CSH therapy, have shown benefits.
7. ^ Rafferty J (October 2018). "Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents". Pediatrics. 142 (4): e20182162. doi:10.1542/peds.2018-2162. PMID 30224363. Often, pubertal suppression...reduces the need for later surgery because physical changes that are otherwise irreversible (protrusion of the Adam's apple, male pattern baldness, voice change, breast growth, etc) are prevented. The available data reveal that pubertal suppression in children who identify as TGD generally leads to improved psychological functioning in adolescence and young adulthood.
8. ^ Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, et al. (November 2017). "Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline". The Journal of Clinical Endocrinology and Metabolism. 102 (11): 3869–3903. doi:10.1210/jc.2017-01658. PMID 28945902. Treating GD/gender-incongruent adolescents entering puberty with GnRH analogs has been shown to improve psychological functioning in several domains", "In the future, we need more rigorous evaluations of the effectiveness and safety of endocrine and surgical protocols. Specifically, endocrine treatment protocols for GD/gender incongruence should include the careful assessment of the following: (1) the effects of prolonged delay of puberty in adolescents on bone health, gonadal function, and the brain (including effects on cognitive, emotional, social, and sexual development);
9. Tordoff, Diana M.; Wanta, Jonathon W.; Collin, Arin; Stepney, Cesalie; Inwards-Breland, David J.; Ahrens, Kym (25 February 2022). "Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care". JAMA Network Open. 5 (2): e220978. doi:10.1001/jamanetworkopen.2022.0978. PMC 8881768. PMID 35212746.
10. ^ Murchison G, Adkins D, Conard LA, Elliott T, Hawkins LA, Newby H, et al. (September 2016). Supporting and Caring for Transgender Children (PDF) (Report). American Academy of Pediatrics. p. 11. To prevent the consequences of going through a puberty that doesn't match a transgender child's identity, healthcare providers may use fully reversible medications that put puberty on hold.
11. https://www.news-medical.net/news/20210415/Endocrine-Society-opposes-legislative-efforts-to-prevent-access-to-medical-care-for-transgender-youth.aspx
12. https://www.wpath.org/media/cms/Documents/USPATH/2022/With%20Date%20Position%20Statement%20Anti%20Trans%20Leg%20USPATH%20Apr%2022%202022.pdf?_t=1650665621
13. Choi, Annette; Mullery, Will (6 June 2023). "19 states have laws restricting gender-affirming care, some with the possibility of a felony charge". CNN. Retrieved 17 September 2023.
14. Alfonseca, Kiara (22 May 2023). "Map: Where gender-affirming care is being targeted in the US". ABC News. Retrieved 14 August 2023.
15. ^ Watson SE, Greene A, Lewis K, Eugster EA (June 2015). "Bird's-eye view of GnRH analog use in a pediatric endocrinology referral center". Endocrine Practice. 21 (6): 586–9. doi:10.4158/EP14412.OR. PMC 5344188. PMID 25667370.
16. Helyar, Sinead; Jackson, Laura; Patrick, Leanne; Hill, Andy; Ion, Robin (May 2022). "Gender Dysphoria in children and young people: The implications for clinical staff of the Bell V's Tavistock Judicial Review and Appeal Ruling". Journal of Clinical Nursing. 31 (9–10): e11–e13. doi:10.1111/jocn.16164. PMID 34888970. S2CID 245029743.
17. "About puberty blockers" (PDF). Oregon Health & Science University. 2020.
18. Panday K, Gona A, Humphrey MB (October 2014). "Medication-induced osteoporosis: screening and treatment strategies". Therapeutic Advances in Musculoskeletal Disease. 6 (5): 185–202. doi:10.1177/1759720X14546350. PMC 4206646. PMID 25342997.
19. Boyar RM (November 2003). "Control of the onset of puberty". Annual Review of Medicine. 29: 509–20. doi:10.1146/annurev.me.29.020178.002453. PMID 206190.
20. ^ Rew, Lynn; Young, Cara C.; Monge, Maria; Bogucka, Roxanne (February 2021). "Review: Puberty blockers for transgender and gender diverse youth-a critical review of the literature". Child and Adolescent Mental Health. 26 (1): 3–14. doi:10.1111/camh.12437. ISSN 1475-357X. PMID 33320999. S2CID 229282305.
21. "Gender dysphoria - Treatment". nhs.uk. 3 October 2018. Retrieved 31 March 2022.
22. Wilson, Lena (11 May 2021). "What Are Puberty Blockers?". The New York Times. ISSN 0362-4331. Retrieved 31 March 2022.
23. ^ Terhune, Chad; Respaut, Robin; Conlin, Michelle (6 October 2022). "As children line up at gender clinics, families confront many unknowns". Reuters. Retrieved 10 October 2022.
24. American Academy of Pediatrics (March 2014). "Off-Label Use of Drugs in Children" (PDF). Pediatrics. 133 (3): 563–567. doi:10.1542/peds.2013-4060. PMID 24567009. S2CID 227262172.
25. ^ Rosenthal SM (December 2016). "Transgender youth: current concepts". Annals of Pediatric Endocrinology & Metabolism. 21 (4): 185–192. doi:10.6065/apem.2016.21.4.185. PMC 5290172. PMID 28164070. The primary risks of pubertal suppression in gender dysphoric youth treated with GnRH agonists include adverse effects on bone mineralization, compromised fertility, and unknown effects on brain development.
26. Coleman, E.; Radix, A.E.; Bouman, W.P.; et al. (2022). "Standards of Care for the Health of Transgender and Gender Diverse People, Version 8". International Journal of Transgender Health. 23 (Supl 1): S18, S64, S111. doi:10.1080/26895269.2022.2100644. PMC 9553112. PMID 36238954.
27. "Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria". 2020. Archived from the original on 22 April 2021. Retrieved 1 April 2021.
28. von der Gönna, Uta (27 February 2024). "Trans identity in minors: Review evaluates current evidence on use of puberty blockers and cross-sex-hormones". Medical Xpress.
29. Zepf, Florian D. (2024). "Beyond NICE: Aktualisierte systematische Übersicht zur Evidenzlage der Pubertätsblockade und Hormongabe bei Minderjährigen mit Geschlechtsdysphorie". Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie. doi:10.1024/1422-4917/a000972.
30. ^ Horton, Cal (14 March 2024). "The Cass Review: Cis-supremacy in the UK's approach to healthcare for trans children". International Journal of Transgender Health: 1–25. doi:10.1080/26895269.2024.2328249. ISSN 2689-5269.
31. "Joint statement EPATH and WPATH" (PDF). World Professional Association for Transgender Health, European Professional Association for Transgender Health. 30 October 2023.
32. Cohen-Kettenis, Peggy T.; Schagen, Sebastiaan E. E.; Steensma, Thomas D. (August 2011). "Puberty suppression in a gender-dysphoric adolescent: A 22-year follow-up". Archives of Sexual Behavior. 40 (4): 843–847. doi:10.1007/s10508-011-9758-9. PMC 3114100. PMID 21503817.
33. Mahfouda, Simone; Moore, Julia K; Siafarikas, Aris; Zepf, Florian D; Lin, Ashleigh (2017). "Puberty suppression in transgender children and adolescents". The Lancet Diabetes & Endocrinology. 5 (10): 816–826. doi:10.1016/s2213-8587(17)30099-2. ISSN 2213-8587.
34. "Team of Experts Provides Critical Review of Florida Medical Report on Transgender Care | Yale Law School". law.yale.edu. 13 July 2022. Retrieved 20 March 2024.
35. O’Connell, Michele A; Nguyen, Thomas P; Ahler, Astrid; Skinner, S Rachel; Pang, Ken C (3 September 2021). "Approach to the Patient: Pharmacological Management of Trans and Gender-Diverse Adolescents". The Journal of Clinical Endocrinology and Metabolism. 107 (1): 241–257. doi:10.1210/clinem/dgab634. ISSN 0021-972X. PMC 8684462. PMID 34476487.
36. Rosenthal, Stephen M. (2014). "Approach to the Patient: Transgender Youth: Endocrine Considerations". The Journal of Clinical Endocrinology & Metabolism. 99 (12): 4379–4389. doi:10.1210/jc.2014-1919. ISSN 0021-972X.
37. OLSON-KENNEDY, JOHANNA (2023). "Expert Rebuttal Report of Johanna Olson-Kennedy, M.D., M.S." (PDF). ACLU. p. 18-19. Retrieved 20 March 2024.
38. "Finnish guidelines for treatment of child and adolescent gender dysphoria" (PDF). Council for Choices in Health Care (COHERE). March 2021. Archived (PDF) from the original on 3 December 2020. Retrieved 22 April 2021. p. 6: Terveydenhuoltolain mukaan (8§) terveydenhuollon toiminnan on perustuttava näyttöön ja hyviin hoito- ja toimintakäytäntöihin. Alaikäisten osalta tutkimusnäyttöön perustuvia terveydenhuollon menetelmiä ei ole. [According to the Health Care Act (Section 8), health care activities must be based on evidence and good care and operating practices. There are no research-based health care methods for minors.]
39. Rafferty, Jason; Committee on Psychosocial Aspects of Child and Family Health; Committee On Adolescence; Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness; et al. (1 October 2018). "Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents". Pediatrics. 142 (4): e20182162. doi:10.1542/peds.2018-2162. ISSN 0031-4005. PMID 30224363. Archived from the original on 19 July 2019. Retrieved 11 June 2021.
40. Abels, Grace. "Trans surgery for minors limited in Europe, not banned". @politifact. Retrieved 20 March 2024.
41. "Puberty Blockers". www.stlouischildrens.org. Archived from the original on 3 August 2022. Retrieved 18 August 2022.
42. Bangalore Krishna, Kanthi; Fuqua, John S.; Rogol, Alan D.; Klein, Karen O.; Popovic, Jadranka; Houk, Christopher P.; Charmandari, Evangelia; Lee, Peter A.; Freire, A. V.; Ropelato, M. G.; Yazid Jalaludin, M. (2019). "Use of Gonadotropin-Releasing Hormone Analogs in Children: Update by an International Consortium". Hormone Research in Paediatrics. 91 (6): 357–372. doi:10.1159/000501336. ISSN 1663-2826. PMID 31319416. GnRHa therapy prevents maturation of primary oocytes and spermatogonia and may preclude gamete maturation, and currently there are no proven methods to preserve fertility in early pubertal transgender adolescents.
43. Benisek, Alexandra (16 May 2022). "What Are Puberty Blockers?". WebMD.
44. ^ Giovanardi G (September 2017). "Buying time or arresting development? The dilemma of administering hormone blockers in trans children and adolescents". Porto Biomedical Journal. 2 (5): 153–156. doi:10.1016/j.pbj.2017.06.001. PMC 6806792. PMID 32258611.
45. ^ de Vries AL, Cohen-Kettenis PT (2012). "Clinical management of gender dysphoria in children and adolescents: the Dutch approach". Journal of Homosexuality. 59 (3): 301–20. doi:10.1080/00918369.2012.653300. PMID 22455322. S2CID 11731779.
46. Jewett-Kaiser, Christina (2 February 2017). "Drug used to halt puberty in children may cause lasting health problems". STAT. Retrieved 8 August 2023.
47. "Risk of pseudotumor cerebri added to labeling for gonadotropin-releasing hormone agonists". publications.aap.org. 1 July 2022. eISSN 1556-3332. Retrieved 18 August 2022.
48. "Risk of pseudotumor cerebri added to labeling for gonadotropin-releasing hormone agonists" (PDF). fda.gov. 1 July 2022.
49. Davis, Erin (27 July 2022). "FDA issues warning on puberty blockers; some Ala. lawmakers support findings". www.wsfa.com. Retrieved 12 September 2022.
50. Baxendale, Sallie (9 February 2024). "The impact of suppressing puberty on neuropsychological function: A review". Acta Paediatrica (Oslo, Norway: 1992). doi:10.1111/apa.17150. ISSN 1651-2227. PMID 38334046.
51. ^ Tuvemo T (May 2006). "Treatment of central precocious puberty". Expert Opin Investig Drugs. 15 (5): 495–505. doi:10.1517/13543784.15.5.495. PMID 16634688. S2CID 34018785.
52. ^ Eugster EA (May 2019). "Treatment of Central Precocious Puberty". J Endocr Soc. 3 (5): 965–972. doi:10.1210/js.2019-00036. PMC 6486823. PMID 31041427.
53. Roth C (September 2002). "Therapeutic potential of GnRH antagonists in the treatment of precocious puberty". Expert Opin Investig Drugs. 11 (9): 1253–9. doi:10.1517/13543784.11.9.1253. PMID 12225246. S2CID 9146658.
54. Rosenthal SM (October 2021). "Challenges in the care of transgender and gender-diverse youth: an endocrinologist's view". Nat Rev Endocrinol. 17 (10): 581–591. doi:10.1038/s41574-021-00535-9. PMID 34376826. S2CID 236972394.
55. Neyman A, Fuqua JS, Eugster EA (April 2019). "Bicalutamide as an Androgen Blocker With Secondary Effect of Promoting Feminization in Male-to-Female Transgender Adolescents". J Adolesc Health. 64 (4): 544–546. doi:10.1016/j.jadohealth.2018.10.296. PMC 6431559. PMID 30612811.
56. ^ Schoelwer M, Eugster EA (2016). "Treatment of Peripheral Precocious Puberty". Puberty from Bench to Clinic. Endocrine Development. Vol. 29. pp. 230–9. doi:10.1159/000438895. ISBN 978-3-318-02788-4. PMC 5345994. PMID 26680582.
57. Lepore, Christina; Alstott, Anne; McNamara, Meredithe (1 October 2022). "Scientific Misinformation Is Criminalizing the Standard of Care for Transgender Youth". JAMA Pediatrics. 176 (10): 965–966. doi:10.1001/jamapediatrics.2022.2959. PMID 35994256. S2CID 251721068.
58. Fitzsimons, Tim (27 September 2019). "A viral fake news story linked trans health care to 'thousands' of deaths". NBC News.
59. McNamara, Meredithe; Abdul-Latif, Hussein; Boulware, Susan D.; Kamody, Rebecca; Kuper, Laura E.; Olezeski, Christy L.; Szilagyi, Nathalie; Alstott, Anne (1 September 2023). "Combating Scientific Disinformation on Gender-Affirming Care". Pediatrics. 152 (3). doi:10.1542/peds.2022-060943. PMID 37605864. S2CID 261062959.
60. Gavulic, Kyle; Bhat, Shamik; Shanab, Bassel (29 June 2022). "Calling Out Scientific Misinformation and Protecting Transgender Youth".
61. Cohen D, Barnes H (September 2019). "Gender dysphoria in children: puberty blockers study draws further criticism". BMJ (Clinical Research Ed.). 366: l5647. doi:10.1136/bmj.l5647. PMID 31540909. S2CID 202711942.
62. ^ Priest M (February 2019). "Transgender Children and the Right to Transition: Medical Ethics When Parents Mean Well but Cause Harm". American Journal of Bioethics. 19 (2): 45–59. doi:10.1080/15265161.2018.1557276. PMID 30784385. S2CID 73456261.
63. Butler G, Wren B, Carmichael P (June 2019). "Puberty blocking in gender dysphoria: suitable for all?". Archives of Disease in Childhood. 104 (6): 509–510. doi:10.1136/archdischild-2018-315984. PMID 30655266. S2CID 58539498.
64. The Lancet Child & Adolescent Health (14 May 2021). "A flawed agenda for trans youth". The Lancet Child & Adolescent Health. 5 (6): 385. doi:10.1016/S2352-4642(21)00139-5. ISSN 2352-4642. PMID 34000232. S2CID 234769856.
65. Ashley F (February 2019). "Puberty Blockers Are Necessary, but They Don't Prevent Homelessness: Caring for Transgender Youth by Supporting Unsupportive Parents". American Journal of Bioethics. 19 (2): 87–89. doi:10.1080/15265161.2018.1557277. PMID 30784386. S2CID 73478358.
66. Jorgensen, Sarah C. J.; Hunter, Patrick K.; Regenstreif, Lori; Sinai, Joanne; Malone, William J. (September 2022). "Puberty blockers for gender dysphoric youth: A lack of sound science". Journal of the American College of Clinical Pharmacy. 5 (9): 1005–1007. doi:10.1002/jac5.1691. ISSN 2574-9870.
67. Carmichael P, Butler G, Masic U, Cole TJ, De Stavola BL, Davidson S, et al. (February 2021). "Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK". PLOS One. 16 (2): e0243894. Bibcode:2021PLoSO..1643894C. doi:10.1371/journal.pone.0243894. PMC 7853497. PMID 33529227. We found no evidence of change in psychological function with GnRHa treatment as indicated by parent report (CBCL) or self-report (YSR) of overall problems, internalising or externalising problems or self-harm. This is in contrast to the Dutch study which reported improved psychological function across total problems, externalising and internalising scores for both CBCL and YSR and small improvements in CGAS .
68. Zucker KJ (October 2019). "Adolescents with Gender Dysphoria: Reflections on Some Contemporary Clinical and Research Issues". Archives of Sexual Behavior. 48 (7): 1983–1992. doi:10.1007/s10508-019-01518-8. PMID 31321594. S2CID 197663705. According to Cohen-Kettenis, Delemarre-van de Waal, and Gooren (2008), these included the following: (1) the presence of gender dysphoria from early childhood on; (2) an exacerbation of the gender dysphoria after the first signs of puberty; (3) the absence of psychiatric comorbidity that would interfere with a diagnostic evaluation or treatment; (4) adequate psychological and social support during treatment; and (5) a demonstration of knowledge of the sex/gender reassignment process.
69. "Arkansas Lawmakers Override Veto, Enact Transgender Youth Treatment Ban". 6 April 2021.
70. "A Federal Judge Blocks Arkansas Ban On Trans Youth Treatments". NPR. Associated Press. 21 July 2021. Retrieved 17 July 2022.
71. Yurcaba, Jo (14 May 2022). "Judge blocks Alabama's felony ban on transgender medication for minors". NBC News.
72. Rojas, Rick (8 April 2022). "Alabama Governor Signs Ban on Transition Care for Transgender Youth". The New York Times. ISSN 0362-4331. Retrieved 17 July 2022.
73. Tierney Sneed (14 May 2022). "Judge blocks Alabama restrictions on certain gender-affirming treatments for transgender youth". CNN. Retrieved 17 July 2022.
74. Sarkissian, Arek (11 August 2022). "Florida bans Medicaid from covering gender-affirming treatments". Politico.
75. Simon, Scott; Sherburne, Lennon (11 February 2023). "Utah's new law bans gender affirming care for transgender youth". NPR. Retrieved 24 May 2023.
76. Dawson, James (5 April 2023). "Idaho governor signs ban on gender-affirming care for trans youth - OPB". www.opb.org. Retrieved 24 May 2023.
77. "Transgender youth and their families sue over Montana gender-affirming care ban". PBS NewsHour. 9 May 2023. Retrieved 24 May 2023.
78. "North Dakota governor signs law limiting transgender care for minors". www.nbcnews.com. 20 April 2023. Retrieved 24 May 2023.
79. Yurcaba, Jo (15 February 2023). "South Dakota becomes the 6th state to restrict gender-affirming care for minors". www.nbcnews.com. Retrieved 24 May 2023.
80. Rodgers, Arleigh (24 March 2023). "Iowa governor signs gender-affirming care ban, restrictive bathroom law". www.cbsnews.com. Retrieved 24 May 2023.
81. "Indiana, Idaho governors sign bans on gender-affirming care". AP NEWS. 5 April 2023. Retrieved 24 May 2023.
82. Schreiner, Bruce (29 March 2023). "GOP lawmakers override veto of transgender bill in Kentucky". AP NEWS. Retrieved 24 May 2023.
83. Alfonseca, Kiara. "Mississippi governor signs transgender health care ban for minors". ABC News. Retrieved 24 May 2023.
84. Rummler, Orion (16 March 2023). "Trans youth in Florida can no longer start gender-affirming care, pushing families toward difficult decisions". The 19th. Retrieved 24 May 2023.
85. Willingham, Leah (29 March 2023). "West Virginia governor signs ban on gender-affirming care for transgender youth". PBS NewsHour. Retrieved 24 May 2023.
86. "Tennessee Bans Gender-Affirming Care for Transgender Youth". American Civil Liberties Union. Retrieved 24 May 2023.
87. Murphy, Sean (2 May 2023). "Oklahoma governor signs gender-affirming care ban for kids". AP NEWS. Retrieved 24 May 2023.
88. Breen, Daniel (21 June 2023). "Federal judge blocks the country's first ban on gender-affirming care for minors". NPR.
89. Block, Melissa. "Parents raise concerns as Florida bans gender-affirming care for trans kids". NPR.
90. Schott, Bryan. "Why GOP lawmakers want to stop doctors from prescribing gender-affirming care for Utah's youth". The Salt Lake Tribune. Retrieved 14 August 2023.
91. Connell-Bryan, Annie; Kenen, Joanne; Holzman, Jael (27 November 2022). "Conservative states are blocking trans medical care. Families are fleeing". Politico.
92. Ramirez, Marc. "As state laws target transgender children, families flee and become 'political refugees'". USA Today.
93. Yurcaba, Jo (19 April 2021). "'It's not safe': Parents of trans kids plan to flee their states as GOP bills loom". NBC News.
94. "USPATH Position Statement on Legislative and Executive Actions Regarding the Medical Care of Transgender Youth" (PDF). WPATH. 22 April 2022. Retrieved 28 August 2022.
95. "Questioning America's approach to transgender health care". The Economist. 28 July 2022. Retrieved 6 August 2022.
96. "Legal". Parents of Gender Diverse Children.
97. "Doubts are growing about therapy for gender-dysphoric children". The Economist. Retrieved 19 March 2024.
98. "Medical treatment methods for dysphoria associated with variations in gender identity in minors – recommendation" (PDF). Council for Choices in Health Care in Finland (Palveluvalikoima). 16 June 2020. Retrieved 4 May 2023.
99. Karjaralainen, Jonna (26 June 2020). ""Jos olisin lääkäri, minua pelottaisi ihan hirveästi antaa diagnooseja", sanoo transmies Susi Nousiainen – transsukupuolisten uusista hoitosuosituksista nousi kohu, tästä siinä on kyse" (in Finnish). Retrieved 17 March 2024.
100. Davis Jr., Elliott (12 July 2023). "European Countries Restrict Trans Health Care for Minors". U.S. News.
101. ^ Phan, Karena (8 June 2023). "Norway didn't ban gender-affirming care for minors, as headline falsely claims". AP News. Retrieved 17 March 2024.
102. "Utredning, behandling og oppfølging". Helsedirektoratet (in Norwegian). Retrieved 17 March 2024.
103. ^ Block, Jennifer (23 March 2023). "Norway's guidance on paediatric gender treatment is unsafe, says review". The British Medical Journal. 380: 697. doi:10.1136/bmj.p697. PMID 36958723. S2CID 257666327. Retrieved 4 June 2023.
104. "Doubts are growing about therapy for gender-dysphoric children". The Economist. 13 May 2021. Archived from the original on 10 August 2023. Retrieved 2 November 2021.
105. "Care of children and adolescents with gender dysphoria: Summary" (PDF). The National Board of Health and Welfare (Socialstyrelsen). 2015. Archived from the original (PDF) on 19 May 2023. Retrieved 4 May 2023.
106. ^ "Uppdaterade rekommendationer för hormonbehandling vid könsdysfori hos unga". The National Board of Health and Welfare (Socialstyrelsen) (in Swedish). 22 February 2022. Archived from the original on 3 August 2023. Retrieved 4 May 2023.
107. Linander, Ida; Alm, Erika (20 April 2022). "Waiting for and in gender-confirming healthcare in Sweden: An analysis of young trans people's experiences" (PDF). European Journal of Social Work. 25 (6). Routledge: 995–1006. doi:10.1080/13691457.2022.2063799. S2CID 248314474. Archived (PDF) from the original on 26 September 2022. Retrieved 11 October 2022.
108. Linander, Ida; Lauri, Marcus; Alm, Erika; Goicolea, Isabel (June 2021). "Two Steps Forward, One Step Back: A Policy Analysis of the Swedish Guidelines for Trans-Specific Healthcare". Sexuality Research and Social Policy. 18 (2): 309–320. doi:10.1007/s13178-020-00459-5. S2CID 219733261.
109. "Women and Gaming; ICU nurse Dawn Bilbrough; Poulomi Basu; Puberty blockers". Woman's Hour. 30 June 2020. Retrieved 1 November 2021.
110. Savage, Rachel (16 September 2020). "UK doctors back trans self-ID rules and treatment for under-18s". U.S. Retrieved 17 May 2023. The BMA called for trans people to receive healthcare "in settings appropriate to their gender identity" and for under-18s to be able to get treatment "in line with existing principles of consent", which requires they fully understand what is involved.
111. "Interim service specification for specialist gender dysphoria services for children and young people – public consultation". NHS UK. 20 October 2022. Retrieved 31 December 2022.
112. "Implementing advice from the Cass Review". NHS UK. 2022. Retrieved 4 May 2023.
113. ^ "England's health service to stop prescribing puberty blockers to transgender kids". CNN.
114. "NHS says children to no longer receive puberty blockers at gender identity clinics". The Independent.
115. "Children Will No Longer Be Able to Access Puberty Blockers at England Clinics". Time.
116. "March 26, 2021: State Advocacy Update". American Medical Association. 26 March 2021.
117. "Proposed Talking Points to Oppose Gender-Affirming Care Criminalization Bills". apa.org. American Psychological Association. Archived from the original on 5 May 2021. Retrieved 11 October 2022.
118. Wyckoff, Alyson Sulaski (6 January 2022). "AAP continues to support care of transgender youths as more states push restrictions". American Academy of Pediatrics. eISSN 1556-3332.
119. "Endocrine Society opposes legislative efforts to prevent access to medical care for transgender youth". 15 April 2021.
120. "AACAP Statement Responding to Efforts to ban Evidence-Based Care for Transgender and Gender Diverse Youth". 8 November 2019.
121. "Position Statement on Treatment of Transgender (Trans) and Gender Diverse Youth" (PDF). psychiatry.org. July 2020. Retrieved 28 August 2022.
122. "Discriminatory policies threaten care for transgender, gender diverse individuals". 16 December 2020.
123. ^ "Frontline Physicians Oppose Legislation That Interferes in or Penalizes Patient Care".
124. "AACE Position Statement: Transgender and Gender Diverse Patients and the Endocrine Community".
125. "ANA Opposes Restrictions on Transgender Healthcare and Criminalizing Gender-Affirming Care". 26 October 2022.
126. Loffman, Matt (16 April 2021). "New poll shows Americans overwhelmingly oppose anti-transgender laws". PBS.
127. "Poll: Majority of U.S. Adults Oppose Anti-LGBTQ Education Policies, Agree that Transgender Youth Should Have Access to Gender-Affirming Care". The Trevor Project. 30 March 2022. Retrieved 30 August 2022.
128. "LGBTQ+ Content Bans and Gender-Affirming Medical Care" (PDF). The Trevor Project and Morning Consult. March 2022. Retrieved 27 October 2022.
129. Gans, Jared (6 May 2023). "Majority of Americans oppose gender-affirming care for minors, trans women participating in sports: poll". The Hill. The Hill. Retrieved 3 June 2023.
130. Bates, Suzanne (19 January 2023). "Transgender issues in schools and states: New poll shows how Americans feel". Deseret News. Archived from the original on 12 September 2023. Retrieved 25 October 2023.
131. Rummler, Orion (18 September 2023). "How personal relationships influence views on gender-affirming care". The 19th. Archived from the original on 22 October 2023. Retrieved 25 October 2023.

External links

• Puberty Inhibitors, by Norman P. Spack, TransYouth Family Allies at the Wayback Machine (archived 2012-04-23)

• Gender transitioning and medicine
• Puberty
• Puberty blockers