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Timing Puberty with Gender-Affirming Care

At what stage of puberty should I start blockers or hormones

In short, when you feel the time is right for you to start your gender-affirming pathway, then that is the right time. We want to mimic the average cisgender teenager experience, by preventing the wrong puberty or avoiding too early or too late a puberty.

Your gender is unique to you and how you want to navigate your gender-affirming care is also unique to you. Of course we don’t need to block a puberty that hasn’t yet started, and we don’t want to block it so late that the developments have already happened. Similarly, we don’t want to induce a puberty when a child is not ready, and nor do we want a teenager to be delayed in their adolescent development.

Gender-affirming care should be tailored to the needs of the person.

Why do we need to wait for puberty to start before starting puberty blockers?

Puberty blockers work by stopping the signals from the brain to the gonads (ovaries or testicles) to stop them from producing the sex hormones that bring about the pubertal developments. If puberty hasn’t started yet, there is nothing to block. There is some thought that gender expression changes as a child goes from prepubertal into adolescence. However, young people who are established and settled in their gender identity, whether that be a cisgender identity or a transgender identity won’t suddenly switch simply because puberty has just started. However, of course how they express their gender through things like clothing or appearance will develop throughout life.

How do I know if puberty has started?

Puberty starts very slowly as the signals from the brain awakening the testicles or ovaries, and the initial changes can be very subtle to spot. This is further confused by the adrenal gland which wakes up some months before the gonads so, causing hair to develop and sweat to start. However, when breast buds form or the testicles and penis start to grow and develop, that is a sign that puberty is underway.

Do I need to have blood tests to confirm the start of puberty?

That is entirely up to you. If you want to have some tests such as FSH or LH, or test for the levels of estradiol or testosterone then that is an option for you, but the signs of puberty are enough to confirm that puberty has started.

Have I got to act quickly when puberty starts?

Puberty starts and progresses very slowly and gradually, and any initial changes can reverse when puberty is blocked. So there is no absolute hurry, although it is good to be prepared in thinking how you might want to suppress puberty and what options there are available.

How are puberty blockers given?

The best blockers are the GnRHa agonists and these can be given by injection (either monthly or every three months) or by a nasal spray. These options can be expensive if you are having to pay for the medication yourself, but there is a tablet version – spironolactone – which helps to suppress the effects of testosterone in people with testicles.

At what stage of puberty can I start gender-affirming hormones?

Gender-affirming hormones will cause your body to develop the secondary sex characteristics associated with that hormone. So if you take testosterone, your skeleton, your facial and body hair and your voice will all become more masculine. If you take estrogen, your breasts, body shape and skin will all become more feminine. These changes are slow to develop, just like with natural puberty, but they will eventually be irreversible. However, when you understand these effects and are ready to undertake this step, then that is the right time for you.

Do I have to wait for puberty to start to take hormones?

Every person is completely individual in when they start puberty, whether they are cisgender or transgender. If you are cisgender and are going to start your puberty naturally, then people who reach the age of 14 without having started puberty yet are considered to be delayed, and would be given hormones to kick things off. The same philosophy should be applied to transgender children who are stable and settled in their gender identity. Early and late puberty causes issues with physical, social and psychological development, and we want teenagers to have their puberty during their mid teens.

Why is it important to establish that puberty has commenced?

It is important to demonstrate that puberty has commenced for gender affirming healthcare because the pubertal stage informs decisions about when to commence treatment and dosing regimens. To commence puberty blocking medication, a young person should have reached Tanner stage 2.

The dosing regimen for gender-affirming hormone treatment depends on the pubertal stage. Lower doses of oestrogen or testosterone are used when treatment is commenced in early puberty (Tanner stage 2) than when treatment is commenced in later puberty (Tanner stages 3 and 4). This is to make the treatment resemble the hormonal changes of physiological puberty as closely as possible.

How is puberty demonstrated?

Puberty is a gradual process that takes several years to complete. The different stages of puberty are usually classified using the Tanner scale (named after the paediatrician James Tanner). The scale goes from stage 1 (before puberty begins) to stage 5 (puberty completed). In this scale are features associated with the different Tanner stages in people born with ovaries and people born with testes. However, it is important to note that people’s bodies differ and may vary concerning these features.

The onset of puberty can be self-diagnosed by examining the body for the changes described in the above Tanner scale. This can be performed by yourself in the privacy of your own home.

Importantly, a self-diagnosis of puberty cannot be based solely on pubic hair growth but must also consider other bodily changes. This is to distinguish genuine puberty from adrenarche, which can also cause some pubic hair growth but not other physical changes.

In people with ovaries, the commencement of puberty (Tanner stage 2) is marked by one or more of the following bodily changes in addition to pubic hair growth:

  • Development of breast buds that can be felt upon gentle pressing;
  • Pigmentation of the skin of the labia;
  • Enlargement of the clitoris.

In people with testes, the commencement of puberty (Tanner stage 2) is marked by one or more of the following bodily changes in addition to pubic hair growth:

  • Increase in testicular size to 2.5–3.2 cm;
  • A change in texture and pigmentation of the skin on the scrotum.

Blood tests for hormone levels are generally unreliable for diagnosing puberty. This is because hormone levels vary significantly from person to person during puberty. So there are no reliable reference ranges that correspond to different Tanner stages. Therefore, blood tests are not recommended for diagnosing puberty.

Do children undergo other bodily changes before puberty?

Some years before puberty, usually between ages 6 and 8, children undergo another developmental process called the adrenarche. This marks the maturation of the adrenal glands, specialised glands above the kidneys that produce hormones involved in salt regulation.

During adrenarche, the adrenal glands produce various hormones, including androgens, which have similar effects to testosterone. This can result in subtle bodily changes, such as physical hair growth, altered body odour, and acne. However, adrenarche does not usually cause changes such as breast development or testicular enlargement, unlike puberty.

Updated on January 26, 2024

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