Puberty Blockers: What They Are and How They Work

Diagram showing how sex hormones are released and the effect of puberty blockers

It crossed my mind that we often talk about puberty blockers without actually talking about what they are, so I wanted to do this post to help fill that gap.

The hormone party

There are three types of hormones and hormone-releasing areas that are relevant here:

  • Hypothalamus: The hypothalamus is the brain’s hormonal air traffic control centre. When the brain decides it’s time to start up the puberty bus (okay, I’m mixing metaphors here), it revs the hypothalamic engine, sending pulses of GnRH (gonadotropin releasing hormone).
  • Pituitary gland: This is also in the brain. It notices the pulses of GnRH and realizes that it’s time to get this party started. It produces two different hormones, LH (luteinizing hormone) and FSH (follicle stimulating hormone), to tell the ovaries and testes that it’s party time.
  • Gonads (ovaries & testes): These release estrogen, progesterone, and testosterone. Once these sex hormones are floating around, they trigger the development of secondary sex characteristics and impact bone and muscle development, which ends up making us look masculine or feminine.

When the hypothalamus is releasing bursts of GnRH, the pituitary gland thinks it’s party time. If there are a few weeks of steady levels of GnRH, the pituitary gland realizes the party isn’t happening, so it stops paying any attention to the GnRH.

GnRH analogues

That’s where puberty blockers come in. GnRH analogues (Lupron is a common one) are synthetic versions of the GnRH that our hypothalamus produces, much like Synthroid is a synthetic version of the thyroid hormone our bodies naturally produce. They can be given as long-acting injections that release steady levels of medication into the circulation. They cause an initial surge of hormones, as the pituitary gland thinks it’s party time, but after a few weeks, the pituitary gland concludes that the party’s over, and it stops releasing LH and FSH.

Stopping puberty isn’t the only reason why GnRH analogues can be useful, and its effects have a lot to do with how it’s used and what’s already going on in the body that it’s being used in. They’re used in the treatment of precocious puberty (before age 8 in girls, 9 in boys). They can be used in the treatment of endometriosis and uterine fibroids. Short-acting GnRH formulations are used as part of fertility treatments. In breast and prostate cancers where the cancer cells are feeding on estrogen or testosterone, GnRH analogues are sometimes used to deprive the cancer of some of that food supply (and no, that doesn’t make it a form of chemo). Adults are used to their brains releasing pulses of GnRH every so often so they have lots of sex hormones floating around, and taking GnRH analogues will induce menopause in females or something similar in males.

There are plenty of other hormones that are used in pediatric medicine. Thyroid, adrenal gland, or pituitary gland problems, rickets, diabetes, and growth issues are all treated with hormone analogues. Pediatric endocrinologists are very experienced in hormonal treatments in kids.

Puberty blocking

In the case of puberty blocking, GnRH analogues delay puberty. Once they’re stopped, puberty will carry on as if it hadn’t been interrupted. The hypothalamus will start releasing pulsatile GnRH, and the pituitary gland will realize that the party’s back on, and it’ll start sending out LH and FSH again, and the ovaries and testes will do a happy dance.

So why is this useful? Once someone has developed secondary sex characteristics, you can’t just make those go away, unless you’ve somehow managed to discover a magic wand. These characteristics include breasts, hair distribution, fat distribution, muscle development, height, facial bone structure, and voice. Once the body has masculinized or feminized, you can do all the surgery you want, but it’s not going to entirely do away with the effects of puberty.

Using GnRH analogues is a strategy to buy time by putting off puberty until a decision is made whether to take masculinizing or feminizing sex hormone analogues, and possibly have surgery later down the line. It’s considered a reversible intervention, although there may be some adverse effects on fertility by delaying puberty. It’s not a long-term intervention by any means.

Standards of care

The World Professional Association for Transgender Health has published Standards of Care that address the use of puberty blockers. Criteria for their use include “a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed)” and “Gender dysphoria emerged or worsened with the onset of puberty.”

The drugs are started once puberty has begun, and the recommendation is that they not be started until the child has reached what’s known as Tanner stage 2, where the physical effects of puberty are starting to be noticed, so that it can be established that the start of puberty is worsening the gender dysphoria. There are alternatives to GnRH analogues that may be used instead.

Gender as social construct

I wrote recently about sex and gender, and what’s biology vs. social construct. After having finished the draft of this post, I came across a Youtube clip of Joe Rogan and Jordan Peterson talking about trans kids and hormones. They were arguing that if gender is a social construct, why use hormones?

While I’m sure they think that makes perfect sense, there’s a big ol’ set of blinders going on there, because there’s more to it than that. People want to look “normal” for whatever social groups and categories they identify with. Why? Because if they don’t, they get shit all over. By who? By people like Joe Rogan and Jordan Peterson.

Consequences of a sex/gender mismatch

Joe Rogan says if a kid born male feels like a girl, “just be a girl”; there’s no need for hormones. But let’s say kiddo who’s born male grows up to look like Dwayne Johnson and continues to identify as female. How is society going to react to that? People like Joe Rogan and Jordan Peterson are going to tell that now-adult that they’re a man, not a woman, and they need to quit being a fuck-up pansy-ass snowflake liberal and just be a man. Jordan Peterson will refuse to use her identified pronouns, because he has said that if he sees (what appears to be) a male in front of him, that person is male, end of story.

So, why GnRH analogues? To avoid (some of) that shitstorm. Because the social construct of female and the social construct of male look certain ways. Because our society is unprepared to accept people that don’t fit into the boxes that people like Joe Rogan and Jordan Peterson seem to be so attached to. If society quits being shitty, there’s no need for puberty blockers or any other hormones. That’s why cultures that traditionally accepted a third gender, like the faʻafafine in Samoan culture, don’t need to bother with hormones.

Risks vs. benefits

Getting back to the original point, can GnRH analogues have side effects? Sure. But sending a post-pubertal adult into early menopause isn’t going to be the same as preventing an 11-year-old from proceeding beyond the early stages of puberty. Taking hormones isn’t ideal, but people take birth control pills, thyroid hormone pills, and various other hormone analogues all the time. There will always need to be a risk-benefit analysis, and the benefits of any drug aren’t necessarily going to outweigh the risks.

And the risks of doing nothing are not even close to nil. If puberty proceeds and the body masculinizes or feminizes, and it turns out that’s not the body the individual wants to have as an adult, that’s setting them up for a lifetime of messed-upness. The risks of puberty-blocking drugs can’t be considered in isolation; that potential lifetime of messed-upness absolutely has to figure into the equation. That doesn’t mean that the conclusion will always be that giving GnRH analogues is the right way to go, or that GnRH analogues will always be followed later by masculine/feminine hormones and surgery, but it’s crucial to consider the whole picture.

Does this fit with what you’ve heard about puberty blockers or what you expected them to be? Does it change your thoughts about whether or not they’re appropriate to be used?

18 thoughts on “Puberty Blockers: What They Are and How They Work”

  1. I am new to the world of LGBTQ. Wasn’t in my vocabulary growing up. Trying to educate myself. One of my daughter’s closest friends is trans and did the hormone therapy. The therapy allowed him to present himself to the world the way he felt was accurately him. Not sure why others would care if hormones are used or not. That’s like saying someone objects to the psych meds I take. Not really their business. At all.

  2. I think we already established that I know jack-all about puberty blockers. But this is good information should I ever have to defend my stance on “Be who you are, it’s all good.”

  3. Sorta. I’m always open to new factual information like this. I don’t like the idea of messing with a child’s natural processes unless it is a matter of extreme health concern (like starting puberty at age 8, which definitely seems like a bad idea, at least to me in the Western world). I am suspicious that this new surge of “trans” will fade somewhat and end up at a lower level than it appears to be at now. It seems to be trendy in the celeb world and gets the celebs a lot of attention, which in turn influences young peeps. I wonder how many actual trans people there are, but as you note, it is impossible to remove culture from the analysis. No one grows up with no influences…

    1. What’s key for me with the puberty blockers is that they buy time without actually changing anything. If someone starts puberty at 12, they don’t have to make a decision at that point about taking estrogen or testosterone; they can take the puberty blockers for a few years until they’re more mature and in a better position to make a decision about more permanent interventions.

      As for the faddish aspect, the celebrity world is definitely screwed up. I certainly wouldn’t be surprised if some of the nonbinary identifications (and it seems like in the celeb world there are more of those than other trans identifications) are more about discomfort with trying to be shoved into a gender stereotyped box than having a strong sense of being the opposite gender. The fact that alternate genders are accepted in some traditional Indigenous and non-Western cultures suggests to me that there’s a transgender element that’s quite a bit more solid and enduring than just the Hollywood side of things.

    2. I’ve also known a couple of adult trans women who didn’t have any form of treatment as teens, and they appeared and sounded very masculine. They were misgendered regularly and treated like freaks of nature. It was horrible for them, and one of them ended up taking her own life, so avoiding that type of situation is something that’s very forefront for me when it comes to this issue.

    1. That particular clip was the only time I’ve heard Joe Rogan, but I’ve listened to several Jordan Peterson videos lately out of curiosity, and I’ve encountered some bloggers who think positively about him. What’s scary about Jordan Peterson is that not everything he says is factually incorrect, but he only sees, and seems willing to see, a very small part of the bigger picture. But because he’s got some facts in there, and he’s done his research on those facts, he can come across as very authoritative. It reminds me of that thing about blind men deciding what an elephant is based on feeling different parts of it. Jordan Peterson has studied the tail really closely and seems to have decided with absolutely certainty that because he knows all about the tail in isolation, the rest of the elephant can’t possibly exist. To me, that’s a lot scarier than someone like Joe Rogan, who seems more like a blowhard.

  4. I don’t know what parts of the elephant he does see, but I’ve heard him adamantly deny the possibility of the trunk, head, and legs existing. It’s irrelevant to me what I’ve heard commentators say about him; I’m interested in what comes out nof his mouth 🤷🏻‍♀️ It’s not a perfect metaphor by any means; I added it after publishing the original article in an attempt to make it clearer that I”m not suggesting that Peterson is convinced there’s a giraffe. I have no way of knowing what he thinks of the parts of the elephant I haven’t heard him speak about. I recognize that he’s extremely knowledgeable about the tail. However, to argue that the trunk doesn’t exist simply because it’s not the tail is not a logical conclusion. I’ve heard him argue that certain things don’t exist because (i.e. socially constructed elements to gender) they’re not what he knows and believes about the tail (i.e. that there are biological sex differences that are seen when looking at populations). However, that kind of argument is likely to blind one to the fact that there is more to the bigger picture that’s true than simply what one is saying about a particular aspect of the tail. There is absolutely nothing mutually exclusive in socially constructed elements to gender, biological differences that you only see when you look at populations, as there’s sufficient overlap that they don’t predict the non-sexual characteristics of a given individual, and individuals having experiences that differ from what’ seen on a population level.

    I’m not saying that what he’s claiming about the tail is wrong, although I know that a lot of his critics do say that. My concern is that his arguments that I’ve heard directly from his mouth insist that other parts of the animal are not valid because they’re not the tail. Highly reductionist arguments, whether it’s insisting that the elephant is all tail, or the opposite, insisting the entire elephant is uniform and therefore there is no tail, are likely to miss very important parts of the picture. Non-reductionist approaches that acknowledge complexity seem to be ignored entirely by both extremes of reductionism.
    If people choose to blind themselves to complexity, that their choice, but choosing not to see it doesn’t mean it doesn’t exist.

Leave a Reply