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.
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.
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?