How Are Puberty Blockers Prescribed?
What you need to know about trans kids and puberty blockers.
The most common falsity that exists around trans kids and puberty blockers — or gender-affirming care in general — is that this care happens quickly. Nothing about gender-affirming care is fast.
Here is a fairly common timeline based on the experience I had with my trans son.
1. My child first started to understand they were trans as puberty approached. We were shopping and I mentioned I thought the time had come for us to look for a training bra. He wasn’t what I would call distraught, but he definitively said he did not want a bra.
Now, that’s not necessarily uncommon. Puberty is not a comfortable time for most kids. As our conversations continued, though, what became more evident was that his feelings were beyond general discomfort, and so we began discussing puberty blockers.
2. I googled gender clinics in our area, and emailed for general information, which led to a phone call with an administrative person who walked me though the process of getting to the first appointment, which would happen with a team of health care providers that included an endocrinologist, social worker, therapist and nursing staff.
3. Before that, however, I needed to confirm insurance. No representative at my insurance carrier would give me a straight answer regarding coverage for gender-affirming health care, so I was left to choose to switch to an HMO (they are often required to abide by more mandates, the representative told me) and hoping what my kid needed would be covered.
4. Once insurance was clarified, I started talking with my son’s primary care provider because our HMO required we get a referral. After multiple conversations with his PCP and their insurance person, we were able to secure a referral.
5. The first appointment was three hours long and included meeting with an endocrinologist and a team of other providers who explained what would be happening going forward.
Before beginning puberty blockers, we needed to have bloodwork done and a Dexa scan to benchmark bone age so providers could continue to monitor bone health throughout treatment.
Five months: Time from original outreach to a gender clinic (September 2017) to the first appointment to discuss if puberty blockers were an appropriate treatment for my kid (June 2018).
6. During the first appointment, the endocrinologist determined Tanner Stage . For trans kids, starting puberty blockers at Tanner Stage 2 or 3 is optimal to prevent the development of any secondary sex characteristics that might be unwanted in the future because any development that occurs prior to blockers being started is irreversible and permanent. That is very important to understand.
Puberty blockers do not reverse already existing development, they simply pause/halt further development.
We talked to a social worker about the necessary therapy that would need to occur before prescribing, and we talked about insurance. We discussed the risks (bone density) and the now unknowns (brain development).
Here, it’s imperative to note that brain development was not discussed in a serious manner, meaning there is no evidence that puberty blockers have longstanding adverse effects on brain development. Our endocrinologist said in all her years of practice, she saw no side effects affecting brain development in her trans patients.
For those who argue we shouldn’t be taking any risks, the question becomes: You have a child who is becoming increasingly anxious and unhappy with the way their body is developing because that development does not align with their understanding of themselves. Do you risk potentially slowing development of executive function by a measure likely unnoticeable, for example, to alleviate a child’s anxiety and help them be a healthy, happy kid? Yes.
Because when we talk about any condition requiring blockers that doesn’t involve a trans child, like kids experiencing precocious puberty, these risks aren’t described in the often dramatic and abusive way they’re described when anti-trans people talk about gender-affirming care.
7. Puberty blockers can either be given via injection every one to three months, or via an implant. Our endocrinologist told us plainly at our first appointment: “Your insurance will deny coverage, we’ll appeal, and you’ll have to take whatever puberty blocker is approved.” So, we waited and navigated insurance.
8. Informed consent for any gender-affirming health care for trans kids includes mental health assessment. After that initial appointment, we scheduled appointments to meet with the gender clinic’s therapist, who we saw several times before my child was prescribed puberty blockers.
At the first appointment, the therapist explained what they’d be covering in their sessions. I would be part of some of them and he would meet with my kid alone at others.
Because puberty blockers have physical effects, informed consent included my kid needing to understand how they would work in their body. The therapist drew crude renditions of the brain, ovaries and testes on a whiteboard as he explained what happens during puberty and how puberty blockers would work. Then, he erased the whiteboard and asked my kid to redraw and explain the process, as well as the effects of puberty blockers, in their own words.
(Need a quick refresh on puberty and what puberty blockers do? See this explanation of how puberty blockers are not hormones in Common Myths).
9. After several appointments, the therapists decides if he’ll write a letter of readiness to allow my kid to start puberty blockers. (He did). To gain insurance approval, a trans kid has to demonstrate a history of gender dysphoria or gender nonconformity.
You may hear people talking about the gatekeeping that happens around gender-affirming care, and this is some of what is meant. Trans people are examples of naturally occurring human variation, but often must experience being pathologized in order to gain access to gender-affirming health care. For more on gatekeeping, go here.
10. Blockers are prescribed and the gender clinic works with the pharmacy to make sure insurance is in place and medication is sent before an appointment for first blocker injection is made.
Four months: Time from the first appointment to discuss puberty blockers to my kid receiving their first blocker shot.
So, from the time my kid first voiced their gender may not align with their assigned sex to receiving their first blocker shot, the better part of one year had passed.
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Additional Resources:
Information on the benefits of gender-affirming care for trans kids from the American Medical Association.
Support of gender-affirming health care for trans kids offered by the American Academy of Pediatrics.
