Starting puberty blockers at the onset of puberty is standard care for trans youth. Starting HRT could be, too.

Disclaimer: I am not a medical professional and this is not medical advice.

Zinnia JonesIf a transgender or gender-questioning youth is experiencing the distress of gender dysphoria about changes to their growing body, when – if at all – should they be treated with puberty blockers to pause any progression of their puberty? Before trying to answer that, let’s look at some recent perspectives offered in the media:

  • The Daily Mail described Dr. Helen Webberly and her practice treating transgender youth as “selling puberty blockers to children as young as 12” and stated that she was “giving hormones to children, including 12-year-olds.”
  • Another Daily Mail article stated that Webberly had prescribed puberty blockers to 11-year-olds and testosterone to 12-year-olds.
  • The Manchester Evening News reported that Webberly “gave puberty blockers to kids”, saying that she “had been prescribing hormones and ‘puberty blockers’ to children as young as 12”.
  • The right-wing Daily Wire interviewed a father who sought to interfere with his child’s continued treatment at a Minnesota gender clinic, obtaining “a court order in 2020 to prevent his son, now 11, from receiving further medical intervention at the clinic, which he claims was ‘weeks away’ from issuing a referral for puberty-blocking drugs.” On his website, the father adds that “Because he has reached stage 2 on the SMR, according to the experts at the gender clinic, a treatment of puberty blockers is considered the next ‘standard of care’”.

These accusations suggest it is self-evidently wrong to provide puberty blockers to trans youth at ages 11-12 or cross-sex hormone therapy at age 12. But is this treatment actually so outrageously out of the norm – or out of the norm at all? Again, when should youth with gender dysphoria be given puberty blockers?

Consider these recent and not-so-recent recommendations from specialists in medical transition for trans youth:

  • The Endocrine Society in its 2009 guidelines stated that puberty blockers should be administered at Tanner stage 2 regardless of age: “We recommend that suppression of pubertal hormones start when girls and boys first exhibit physical changes of puberty (confirmed by pubertal levels of estradiol and testosterone, respectively), but no earlier than Tanner stages 2–3.”
  • The Endocrine Society again stated in its 2017 updated guidelines that treatment with puberty blockers should be initiated in “early puberty”, without specifying an age: “We therefore advise starting suppression in early puberty to prevent the irreversible development of undesirable secondary sex characteristics. … Thus, Tanner stage 2 is the optimal time to start pubertal suppression.”
  • Spack et al. (2012), working at the gender clinic of Children’s Hospital Boston, explained why an age-based timeline for treatment with puberty blockers could be inappropriate: “Appropriately screened patients with GID who were at Tanner stage 2 or 3 were offered pubertal suppression with GnRH analogs if they could obtain it. We did not limit our candidates to a minimal age of 12, as the Amsterdam group did. Postponing treatment until age 12 would result in many natal female patients being late Tanner 3 to Tanner 4, postmenarche, decelerating in growth velocity to a female final height…”

Existing guidelines for the timing of treatment with puberty blockers for trans youth – guidelines that have been around for 12 years or more – make clear that this treatment is meant to be used once a child’s natal puberty has begun. They are not being prescribed needlessly to prepubertal youth, who at Tanner stage 1 have not experienced even the beginnings of any changes of puberty. And as the Boston clinicians note, adherence to a specific age threshold would mean mistiming treatment with puberty blockers, only administering them at a later stage of undesired natal puberty when they would be less effective at averting those pubertal changes.

The onset of one’s own natal puberty has never been precisely biologically timed to age 11 or 12; it has always been known that youth start puberty at a range of ages. A recent publication on the Trans Youth Care multisite cohort reported that youth in the study assigned female started puberty blockers as early as age 9, with those assigned male starting as early as age 10 (Schulmeister et al., 2021). A protocol that flexibly times puberty blockers based on when an individual begins to experience puberty can allow this treatment to be delivered when it is most effective, neither needlessly early nor too late to serve its intended purpose.

What these media outlets are portraying as an indefensibly premature treatment has in fact been a part of established routine care for these trans youth for over a decade. Whatever other complaints may be involved in any individual cases and histories of treatment, treating trans youth with puberty blockers is in no way inherently inappropriate simply because it was started at age 11 or 12. The accusation that a doctor “gave puberty blockers to kids” – who else would receive them? – is an accusation that this doctor most likely prescribed this treatment within an appropriate age range.

This timing of puberty blockers is in keeping with accepted protocols for treating trans adolescents. But what about providing cross-sex hormone therapy at age 12 as well? Is this an unacceptably young age? We can look again to existing guidelines and clinical practice:

  • The Endocrine Society’s 2017 guidelines raise the possibility of trans youth receiving HRT at age 13 or earlier: “We recognize that there may be compelling reasons to initiate sex hormone treatment prior to the age of 16 years in some adolescents with GD/gender incongruence, even though there are minimal published studies of gender-affirming hormone treatments administered before age 13.5 to 14 years.”
  • Shumer et al. (2016) explain the emerging practice of providing HRT as early as age 14: “In our practice, we have found that for many patients there is significant psychosocial risk in waiting until age 16 years to start cross-sex hormones if the patient is otherwise stable in their transgender identity. It is therefore our practice, and the practice of similar institutions, to consider cross-sex hormone treatment initiation as young as age 14 years.”
  • Rosenthal (2014) at the UCSF Child and Adolescent Gender Center similarly notes that “gender centers at our institution and elsewhere are studying the impact of cross-sex hormone treatment initiation at 14 years of age (which approximates the upper end of the age range for normal pubertal onset in natal males and 1 year beyond the upper end of the age range in natal females).”
  • Skordis et al. (2018) found that many gender clinics in the Americas are willing to provide HRT from age 14 onward.
  • Forcier (2020), in a course presentation for the Fenway Institute, noted that initiating puberty with HRT in trans youth to be congruent with their cisgender peers would be timed for age 10-11 in those assigned female and age 11-12 in those assigned male.
  • Trans youth in Brik et al. (2020) started puberty blockers as early as age 10 for trans boys and age 11 for trans girls, and started HRT as early as age 14.
  • In an initial study of this medication in trans youth, adolescent trans girls as young as 12 were given bicalutamide, an antiandrogen which serves as a puberty blocker in trans girls and raises estrogen levels (Neyman et al., 2019).
  • In the population of trans boys studied in Olson-Kennedy et al. (2018), some had begun receiving HRT as early as age 12.
  • Lynch et al. (2015) reports one trans girl and one trans boy both starting HRT at age 11.
  • In Khatchadourian et al. (2014), some trans girls and boys studied began receiving HRT as early as age 13.
  • Among the trans youth treated in de Vries et al. (2014), some received puberty blockers at age 11 and HRT at age 13. In a previous study of these subjects, some spent as little as 5 months on only puberty blockers before proceeding to HRT (de Vries et al., 2011).

So: If a trans adolescent with gender dysphoria has been given treatment with HRT at age 12, does their age inherently mean this is an inappropriate treatment? No. That age would not be out of the norm for contemporary clinical practice – they are far from the only trans 12-year-old receiving HRT. The context of “giving hormones to 12-year-olds” certainly does not merit the alarmed tone of the headline, and this news is not at all new.

The now-established and un-newsworthy timing of transition treatments for adolescents, from puberty blockers to HRT, has emerged for good reason. It may not be necessary, or healthy, to delay a child’s experience of puberty until this is induced with HRT in much later adolescence after many years of treatment with only puberty blockers. Initiating HRT in earlier adolescence can come with distinct social and health benefits, as explained by Shumer & Araya (2019):

As discussed, in the initial “Dutch Protocol” the age 16 was used. Many transgender adolescents, however, are deemed to have clear gender dysphoria and are requesting these interventions with parental support at much younger ages. From a social perspective, it may be challenging for a transgender child living in all contexts as their affirmed gender to wait until age 16 to start puberty—an age significantly older than what is typical for their peers. Furthermore, for a child who started GnRH agonist treatment at Tanner stage 2, perhaps as young as 8 or 9 years old, restricting the use of gender-affirming hormone therapy until age 16 would artificially delay their pubertal development, including growth spurt and bone density accrual, by over a half-decade. Given these concerns, many providers treat transgender youth with testosterone or estrogen at ages younger than 16 years. … As the evolution on age continues, providers seem to be acknowledging that individual readiness factors, rather than age cutoffs, are important when considering the use of gender-affirming hormones.

Earlier initiation of HRT has also been found to provide potential benefits in management of pubertal growth for these youth:

  • Treatment of adolescent trans boys with a masculinizing steroid, followed by testosterone, appeared to produce a final adult height 2 inches taller when this was first given at age 13 compared to age 16 (Grimstad et al., 2021).
  • Hellinga et al. (2019) point out that while high-dose estrogens have served to reduce the final adult height of adolescent trans girls, “final height of these transgirls was still above the normal range of biological girls” and “estrogens should be started at an earlier age.”
  • More broadly, Sorbara et al. (2020) found that trans youth who present for evaluation at an older age or later pubertal stage were more likely to experience mental health problems such as depression and anxiety.

Prescribing HRT to trans youth at earlier ages does not appear to be harmful to these children, and it may be helpful to them. 17 state attorneys general, recently opposing these youth being able to access even puberty blockers at any age, inadvertently offered this insight: “The evidence also shows that nearly all children whose gender dysphoria is treated with puberty blockers to ‘buy time’ will proceed to take cross-sex hormones”. This isn’t universally true – some trans or gender-questioning youth, perhaps up to 3.5%, do cease puberty blockers and choose not to transition – but it is substantially true. It just doesn’t mean what anti-trans advocates believe it does.

This very low rate of discontinuation doesn’t reflect a circumstance where very long periods of treatment with only puberty blockers are serving to sift out a significant number of detransitioners over time before they mistakenly receive more permanent HRT. For 96.5% of trans youth on puberty blockers, this years-long deprivation of any sex hormones in the middle of the crucial developmental phase of adolescence may not ultimately be necessary. These youth could instead experience the changes of their desired puberty contemporaneously with their peers, beginning at ages 10-13 in accordance with current practice, with potential benefits to their psychosocial health and adult physical development.

Anti-trans coverage on this subject projects the appearance of being concerned with the unsanctioned and alarming actions of rogue physicians who are irresponsibly treating vulnerable children. But the conduct described is fully within the norm for gender clinics large and small around the globe and has been for many years, no more cause for alarm now than it was in 2009. What the public deserves to know is that the continuing findings of benefits to early transition are cause for celebration. 

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About Zinnia Jones

My work focuses on insights to be found across transgender sociology, public health, psychiatry, history of medicine, cognitive science, the social processes of science, transgender feminism, and human rights, taking an analytic approach that intersects these many perspectives and is guided by the lived experiences of transgender people. I live in Orlando with my family, and work mainly in technical writing.
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