Stopping the Puberty Apocalypse
Imagine for a moment, the unthinkable: a supersized asteroid is on a collision course with Earth, and NASA has no idea how to stop it. Nukes, gravitational slingshots, Bruce Willis? All of them might work, but they only have one shot—if only they had more time to figure out a solution.
This is what puberty can feel like to teenagers questioning their gender identity. Many young teenagers start feeling profound distress between the gender assigned to them at birth and their own experienced gender, just as irreversible developments of secondary sex characteristics start appearing on the horizon, such as a changing voice, redistribution of fat deposits, height, body hair, and more. Gender distress, or dysphoria, is only worsened by watching the body change in ways that feel fundamentally wrong. But puberty is always hard, and with such quick-approaching doom it can be difficult to figure out whether this distress indicates a need for gender transition or rather reflects puberty’s trials. However, unlike the erstwhile NASA scientists in apocalypse sci-fi, these young teenagers can stop time—with puberty blockers.
Puberty blockers are a clever bit of endocrinology: most commonly gonadotropin-releasing hormone (GnRH) agonists, they “pause” the release of sex hormones like testosterone and estrogen that drive puberty. Critically, it is a pause, and if a teenager stops taking GnRH agonists, then puberty will resume just like normal. GnRH agonists in concert with counseling and family support can be crucial to improving the mental well-being of a teenager experiencing gender dysphoria, and additionally ease future gender transition by preventing irreversible dysphoric changes from ever occurring.
Crucially for teenagers—who are generally considered unable to fully consent to life-altering medical procedures—it allows them to mature in gender identity and confidence without the time limit of an impending puberty and development of secondary sex characteristics. For these reasons, puberty blockers are considered part of the standards of care for gender-questioning teenagers by the World Professional Association of Transgender Health.
Unfortunately, access to puberty blockers is spotty across the U.S. Twenty states have introduced legislation banning the use of puberty blockers among teenagers entirely, and Arkansas passed a bill to this effect last April. Just this February, Texas Governor Greg Abbot directed all state employees to report parents of trans children receiving any gender-affirming care for criminal prosecution of child abuse. This isn’t even getting into the vast financial barriers to receiving care, including high prices and poor insurance coverage. These barriers enact cruelty against young teenagers and have serious consequences for their mental and emotional health. The federal government must act by requiring that Medicaid and private insurance plans cover gender-affirming care, and specifically puberty blockers for teenagers, as well as make giving gender-affirming care to teenagers legal.
In Texas, Governor Abbot and other officials have argued that gender-affirming care, including puberty blockers, amount to child abuse. Nothing could be further from the truth—and taking vulnerable trans teenagers away from supportive families will be devasting to their health. Again, GnRH agonists are unique among gender-affirming care because they are fully reversible, and allow teenagers to choose their future. As it is now, hundreds of Texas teens stand to lose their choice entirely. If the teenage reconfirms their desire to transition after reaching an appropriate age, they will stop taking the GnRH agonists and to start rounds of Hormone Replacement Therapy (HRT), which begins the development of desired secondary sex characteristics without having to deal with the relics of a dysphoric puberty.
Alternatively, the teenager can realize that they don’t want to transition and stop taking the puberty blockers to begin an unassisted puberty (about 10 percent of teenagers choose this option). Either way, the teenager is supported by psychologists, social workers, and their family throughout the whole process, and is allowed to make the decision without the negative stress that development of dysphoric sex characteristics can engender, leading to better mental health as a teenager and as an adult.
To be fair, there are concerns about the side effects of GnRH agonists on bone health and height. Prolonged use can weaken bones and affect height, and which is why doctors don’t tend to prescribe puberty blockers for longer than two years. However, most teenagers on GnRH agonists stop taking the puberty blockers after one year, and switch to either HRT or stop seeking transition-related care, and current standards of care involve quarterly doctor visits for assessing growth and bone health.
Puberty is hard for everyone, especially gender-questioning teens who see the dropping of the voice or development of breasts as the end of the world. Adults everywhere need to stand up to ensure that our teenagers get the support they need: federally legal and insurance-covered puberty blockers that will give more teenagers more time.
Anthony Lanzillo is an MPH student in the Department of Sociomedical Sciences.