Editing Puberty blockers

{{content warning|private body parts, puberty, and menstruation}}
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'''Puberty blockers''', also called '''puberty inhibitors''', are drugs used to postpone and temporarily suspend puberty in [[children]] and teenagers. These drugs are called gonadotropin-releasing hormone (GnRH) agonists, and they inhibit the action of [[testosterone]]. Delaying or temporarily suspending puberty is a medical treatment for children whose puberty started abnormally early (precocious puberty). The drugs are also commonly used for children with idiopathic short stature, for whom these drugs can be used to promote development of long bones and increase adult height.<ref>Sara E. Watson, Ariana Greene, Katherine Lewis, and Erica A. Eugster (2015). Bird's-eye view of GnRH analog use in a pediatric endocrinology referral center. ''Endocrine Practice:'' June 2015, Vol. 21, No. 6, pp. 586-589.</ref> Additionally, they are used for [[transgender]] children, including those who identify as [[nonbinary]], to stop the development of features that they consider to mark the wrong sex,<ref name=":0">{{Cite journal|last=Stevens|first=Jaime|last2=Gomez-Lobo|first2=Veronica|last3=Pine-Twaddell|first3=Elyse|date=2015-12-01|title=Insurance Coverage of Puberty Blocker Therapies for Transgender Youth|url=http://pediatrics.aappublications.org/content/136/6/1029|journal=Pediatrics|language=en|volume=136|issue=6|pages=1029–1031|doi=10.1542/peds.2015-2849|issn=0031-4005|pmid=26527547|doi-access=free}}</ref><ref>{{cite web |url=http://www.washingtontimes.com/news/2016/mar/12/looking-at-suppressing-puberty-for-transgender-kid/ |title=Looking at suppressing puberty for transgender kids |publisher=Associated Press |date=March 12, 2016}}</ref><ref>{{cite web |url=https://ww2.kqed.org/futureofyou/2016/08/19/transgender-youth-using-puberty-blockers/ |title=Transgender Youth Using Puberty Blockers |publisher=[[KQED]] |date=August 19, 2016}}</ref> with the intent to provide transgender youth more time to explore their identity.<ref name=":1">{{Cite journal|last=Alegría|first=Christine Aramburu|date=2016-10-01|title=Gender nonconforming and transgender children/youth: Family, community, and implications for practice|journal=Journal of the American Association of Nurse Practitioners|language=en|volume=28|issue=10|pages=521–527|doi= 10.1002/2327-6924.12363|pmid=27031444|issn=2327-6924}}</ref> 

In adults, the same drugs are used to treat endometriosis (a menstrual disorder),<ref>Current treatments for endometriosis, Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/endometriosis/diagnosis-treatment/drc-20354661</ref> prostate cancer, and other conditions.<ref>Smith, M. R. (2006). Treatment-related osteoporosis in men with prostate cancer. ''Clinical Cancer Research, 12''(20 pt 2), 6315-6319.</ref><ref>Panday, K., Gona, A., Humphrey, M. B., (2014). Medication-induced osteoporosis: Screening and treatment strategies. ''Therapeutic Advances in Musculoskeletal Disease, 6,'' 185-202.</ref>

== Medical uses ==
Puberty blockers prevent the development of biological secondary sex characteristics.<ref name=":2">{{Cite journal|last=Bayar|first=R. M.|date=2003-11-28|title=Control of the Onset of Puberty|url=|journal=Annual Review of Medicine|language=en|volume=29|pages=509–520|doi=10.1146/annurev.me.29.020178.002453|pmid=206190|access-date=}}</ref> They slow the growth of sexual organs and production of hormones. Other effects include the suppression of male features of facial hair, deep voices, and Adam's apples for children and adolescents, and the halting of female features of breast development and menstruation.

Transgender youth are a specific target population of puberty blockers to halt the development of natal secondary sex characteristics.<ref name=":0" /> Puberty blockers allow patients more time to solidify their gender identity, without developing secondary sex characteristics.<ref name=":1" /> If a child later decides not to transition to another gender, the effects of puberty blockers can be fully reversed by stopping the medication.<ref name='aap'>{{cite report|date = September 2016| title = Supporting and Caring for Transgender Children| url = https://assets2.hrc.org/files/documents/SupportingCaringforTransChildren.pdf| publisher = American Academy of Pediatrics| page =11| quote = "To prevent the consequences of going through a puberty that doesn’t match a transgender child’s identity, healthcare providers may use fully reversible medications that put puberty on hold."}}</ref> Puberty blockers give a future transgender individual a smoother transition into their desired gender identity as an adult.<ref name=":1" />

While few studies have examined the effects of puberty blockers for gender non-conforming or transgender adolescents, the studies that have been conducted indicate that these treatments are reasonably safe, and can improve psychological well-being in these individuals.<ref name="lancet_pubertyblockers">{{cite journal | last=Mahfouda | first=Simone | last2=Moore | first2=Julia K | last3=Siafarikas | first3=Aris | last4=Zepf | first4=Florian D | last5=Lin | first5=Ashleigh | title=Puberty suppression in transgender children and adolescents | journal=The Lancet Diabetes & Endocrinology | publisher=Elsevier BV | volume=5 | issue=10 | year=2017 | issn=2213-8587 | doi=10.1016/s2213-8587(17)30099-2 | pmid=28546095 | pages=816–826 | ref=harv|quote=The few studies that have examined the psychological effects of suppressing puberty, as the first stage before possible future commencement of CSH therapy, have shown benefits."}}</ref><ref>{{cite journal |last1=Rafferty |first1=Jason |title=Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents |journal=Pediatrics |date=October 2018 |volume=142 |issue=4 |pages=e20182162 |url=https://pediatrics.aappublications.org/content/142/4/e20182162 |accessdate=23 July 2019|quote=Often, pubertal suppression...reduces the need for later surgery because physical changes that are otherwise irreversible (protrusion of the Adam’s apple, male pattern baldness, voice change, breast growth, etc) are prevented. The available data reveal that pubertal suppression in children who identify as TGD generally leads to improved psychological functioning in adolescence and young adulthood.|doi=10.1542/peds.2018-2162 |pmid=30224363 |doi-access=free }}</ref><ref name="Hembree_et_al">{{cite journal |last1=Hembree |first1=Wylie C |last2=Cohen-Kettenis |first2=Peggy T |last3=Gooren |first3=Louis |last4=Hannema |first4=Sabine E |last5=Meyer |first5=Walter J |last6=Murad |first6=M Hassan |last7=Rosenthal |first7=Stephen M |last8=Safer |first8=Joshua D |last9=Tangpricha |first9=Vin |last10=T'Sjoen |first10=Guy G |title=Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline |journal=The Journal of Clinical Endocrinology & Metabolism |date=November 2017 |volume=102 |issue=11 |page=3881|quote=Treating GD/gender-incongruent adolescents entering puberty with GnRH analogs has been shown to improve psychological functioning in several domains|doi=10.1210/jc.2017-01658 |pmid=28945902 |doi-access=free }}</ref> In 2019, a study in the journal ''Pediatrics'' found that access to pubertal suppression during adolescence was associated with a lower odds of lifetime suicidality among transgender people.<ref>{{cite journal |last1=Turban |first1=Jack |title=Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation |journal=Pediatrics |date=February 2020 |volume=145 |issue=2 |page=e2019172 |doi=10.1542/peds.2019-1725 |pmid=31974216 |url=https://pediatrics.aappublications.org/content/145/2/e20191725 |accessdate=11 February 2020|pmc=7073269 }}</ref>

The potential risks of pubertal suppression in gender dysphoric youth treated with GnRH agonists may include adverse effects on bone mineralization.<ref name="rafferty_2018">{{cite journal |last1=Rafferty |first1=Jason |title=Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents |journal=Pediatrics |date=October 2018 |volume=142 |issue=4 |pages=e20182162 |url=https://pediatrics.aappublications.org/content/142/4/e20182162 |accessdate=23 July 2019|doi=10.1542/peds.2018-2162 |pmid=30224363 |doi-access=free }}</ref><ref name=autogenerated1>{{cite journal|pmc=5290172 | pmid=28164070 | doi=10.6065/apem.2016.21.4.185 | volume=21 | issue=4 | title=Transgender youth: current concepts | author=Rosenthal SM | journal=Ann Pediatr Endocrinol Metab | pages=185–192| year=2016 }}</ref>

Research on the long term effects on brain development is limited, but a 2015 study published in the journal ''Psychoneuroendocrinology'' observed the executive functioning in 20 transgender youth treated with puberty blockers compared to untreated youth with gender dysphoria and found that there was no difference in performance.<ref name=autogenerated1 /><ref name="deVries2012">{{cite journal|last1=de Vries|first1=Annelou L. C.|last2=Cohen-Kettenis|first2=Peggy T.|title=Clinical management of gender dysphoria in children and adolescents: the Dutch approach|journal=Journal of Homosexuality|date=2012|volume=59|issue=3|pages=301–320|doi=10.1080/00918369.2012.653300|issn=1540-3602|pmid=22455322}}</ref><ref>{{cite journal |last1=Staphorsius |first1=Annemieke S. |last2=Kreukels |first2=Baudewijntje P.C. |last3=Cohen-Kettenis |first3=Peggy T. |last4=Veltman |first4=Dick J. |last5=Burke |first5=Sarah M. |last6=Schagen |first6=Sebastian E.E. |last7=Wouters |first7=Femke M. |last8=Delemarre-van de Waal |first8=Henriëtte A. |last9=Bakker |first9=Julie |title=Puberty suppression and executive functioning: An fMRI-study in adolescents with gender dysphoria |journal=Psychoneuroendocrinology |date=June 2015 |volume=56 |pages=190–199 |doi=10.1016/j.psyneuen.2015.03.007 |pmid=25837854}}</ref><ref name=":1" />

== Administration ==
The medication that is used in order to stop puberty comes in two forms: injections or an implant.

The injections are [[leuprorelin]] made intramuscularly by a health professional. The patient may need it monthly (Lupron Depot, Lupron Depot-PED) or each 3, 4 or 6 months (Lupron Depot-3 month, Lupron Depot-PED-3 month, Lupron Depot-4 month, Lupron Depot-6 Month).

The implant is a small tube containing [[histrelin]]. The implant needs to be replaced every year, and is implanted subcutaneously in the upper arm. The doctor makes a small cut in the anesthetized skin of the patient and then inserts the implant. The patient must be careful after the operation to keep the cut clean, dry, and to not move the bandage and the surgical strips or stitches used to close the incision on the skin. The drug is then gradually released in the body during 12 months and it has to be replaced by another one later to continue the treatment. The total cost of histrelin treatment with the surgery is $15,000.

The combination of [[bicalutamide]], an [[antiandrogen]], and [[anastrozole]], an [[aromatase inhibitor]], can be used to suppress male puberty as an alternative to [[GnRH analogue]]s, or in the case of gonadotropin-independent precocious puberty, such as in familial male-limited precocious puberty (also known as testotoxicosis) in children who were assigned male at birth, where GnRH analogues are ineffective.<ref name="KreherPescovitz2006">{{cite journal | vauthors = Kreher NC, Pescovitz OH, Delameter P, Tiulpakov A, Hochberg Z | title = Treatment of familial male-limited precocious puberty with bicalutamide and anastrozole | journal = The Journal of Pediatrics | volume = 149 | issue = 3 | pages = 416–20 | date = Sep 2006 | pmid = 16939760 | doi = 10.1016/j.jpeds.2006.04.027 }}</ref><ref name="ReiterMauras2010">{{cite journal | vauthors = Reiter EO, Mauras N, McCormick K, Kulshreshtha B, Amrhein J, De Luca F, O'Brien S, Armstrong J, Melezinkova H | title = Bicalutamide plus anastrozole for the treatment of gonadotropin-independent precocious puberty in boys with testotoxicosis: a phase II, open-label pilot study (BATT) | journal = Journal of Pediatric Endocrinology & Metabolism | volume = 23 | issue = 10 | pages = 999–1009 | date = Oct 2010 | pmid = 21158211 | doi = 10.1515/jpem.2010.161 }}</ref>

== Puberty blockers for transgender youth ==

For all young people, puberty develops in a sequence of five Tanner Stages. These stages do not happen at the same ages for everyone, so some children go through stages years earlier or later than their peers. Before puberty, children are in Tanner Stage One. The earliest that a transgender child is eligible to take puberty blockers is during Tanner Stage Two, which is a span of a few months when the first signs of puberty appear.<ref name="trans bodies 467">Laura Erickson-Schroth, ed. ''Trans Bodies, Trans Selves: A Resource for the Transgender Community.'' Oxford University Press, 2014. P. 467.</ref> 

==See also==
*[[Transition]]
*[[Hormone therapy]]

==References==
{{Reflist|2}}

[[Category:Transition]]