By Ashley Altadonna
Recently, the South Dakota House passed legislation banning physicians in the state from providing gender-affirming care to transgender children. If signed into law, the bill would have made it a misdemeanor for medical providers to perform gender-affirming surgeries or prescribe hormone therapies to children under the age of 16, including punishment of a $2,000 fine and up to a year in jail. The bill died in the South Dakota Senate and thus was not passed into law, but similar bills have been introduced in other states including Colorado, Florida, and South Carolina.
Considering the elevated rates of anxiety, depression, and suicidality found among gender-expansive adolescents, gender-affirming treatments can have a significant impact on their mental health. Trans and non-binary kids whose families and communities support their gender identities often have similar or better rates of happiness compared to their cisgender counterparts.
Although nearly every major medical association has stated that not only is gender-affirming care routinely safe but also considered best practice, there is still some confusion within the general public surrounding care options for transgender people, particularly in the case of puberty suppressing hormones. Misinformation about how these medicines are prescribed and how they work often adds fuel to the fire of discriminatory legislation, and leads to transgender youth not receiving the support they deserve.
Before puberty, gender-affirmative care doesn’t require the use of medical interventions such as surgeries or hormones. Trans and non-binary children can simply change the names and pronouns they use, as well as the ways they express their gender through their clothing or hairstyle. Medical providers do not recommend the use of puberty suppressing treatments until a child has entered the Tanner stage II of puberty, which is typically around age 10–11 for those assigned female at birth and around age 12 for those assigned male at birth (though the age of onset of puberty will vary depending on the child).
Puberty blockers (sometimes also called puberty inhibitors or puberty suppressors) are gonadotropin-releasing hormone (GnRH) analogues, a type of medication that dramatically slows the release of gonadotropins in the body. Gonadotropins are hormones that stimulate the gonads (the ovaries or testes) into producing estrogen and testosterone. Estrogen and testosterone are the hormones that are mainly responsible for the physical changes we typically see during puberty. When the release of gonadotropins is temporarily shut down by the use of puberty blockers, people taking the medication who have ovaries will not produce estrogen and people taking the medication who have testes will not produce testosterone, thus delaying the onset of puberty.
These kinds of prescriptions have been used for some time for a variety of medical purposes, including treating children whose puberty has started early (precocious puberty) or in the treatment of hormone-responsive cancers like prostate or breast cancer.
For transgender youth, the ability of these medications to pause the development of secondary sex characteristics that may be contrary to their gender identity (such as breast growth, facial hair, or a deepening of the voice) can be beneficial in a number of ways. Halting these physiological changes allows transgender youth the option of more time in which to explore their identity. These medications can also provide a smoother experience for those transgender individuals who opt to continue with gender-affirming care as they grow older. For example, a common gender-affirming surgery for transgender men is the surgical reconstruction of the chest to remove excess breast tissue that developed during puberty. If pubescent breast development is avoided through the use of puberty blockers, then there is no future need for an individual to pursue this surgery. Finally, if after having more time to explore their identity, a young person chooses not to continue treatment, discontinuing use of the puberty blockers allows the body’s production of hormones to resume, and for puberty to move forward.
Puberty blocking medications are typically available in two forms: either an injection or an implant. Injections are typically given intramuscularly by a health professional. Patients may need injections monthly or every 3 to 6 months, depending on the prescription. Implants are placed subcutaneously in the upper arm by a doctor, and will need to be replaced yearly.
All medications carry potential risks and side effects, but studies indicate that these treatments are generally safe, and can greatly improve the well-being of users. Research on long-term risks of puberty blockers is currently limited; some studies have shown these medications may have adverse effects on bone mineralization. Additionally, the delay of puberty can cause genital underdevelopment, particularly in those assigned male at birth, which may limit potential surgical reconstructive options later on. Finally, puberty suppression treatment and/or other gender-affirming hormone therapy should be discussed as to its implications for future fertility options. It is important to consult with a healthcare professional who is familiar with current standards in care for transgender populations, and to consider your child’s or your whole health (physical, mental, and emotional) situation, before beginning treatments.
As the benefits of gender-affirming care for trans and non-binary kids are better understood, more families, professionals, and communities may begin to see these treatments as a practical option for helping young people to explore their identities and embrace their authentic selves.
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