The effect of early puberty suppression on treatment options and outcomes in transgender patients

In the past 10–15 years, paediatric transgender care has emerged at the forefront of several general practice and subspecialty guidelines and is the topic of continuing medical education for various medical disciplines. Providers in specialties ranging from family medicine, paediatrics and adolescent medicine to endocrinology, gynaecology and urology are caring for transgender patients in increasing numbers. Current and evolving national and international best practice guidelines recommend offering a halt of endogenous puberty for patients with early gender dysphoria, in whom impending puberty is unacceptable for their psychosocial health and wellness. Pubertal blockade has implications for fertility preservation, transgender surgical care and psychosocial health, all of which must be considered and discussed with the patient and their family and/or legal guardian before initiation. For transgender people who experience gender dysphoria as children, in whom impending puberty is unacceptable for their psychosocial health and wellness, pubertal blockade is a therapeutic option. In this Review, the authors discuss pubertal blockade and its implications for fertility preservation, surgical care and psychosocial health, all of which must be considered and discussed with the patient and their family and/or legal guardian before initiation. Key points Puberty blockade is the earliest point of medical intervention indicated in paediatric patients expressing gender dysphoria and should be initiated as soon as signs of puberty are observed on physical examination. Puberty blockade has been shown to positively affect mental health outcomes in adolescent patients with gender incongruence. Blockade of puberty does affect future fertility options for transgender adults treated early in adolescence and patients should be counselled regarding the options available to them for future fertility. Blockade of puberty prevents the development of secondary sexual characteristics and, therefore, reduces the number of gender-affirming therapies required to transition and also reduces the cost of surgical care. A number of questions remain surrounding early intervention and pubertal blockade, including the future effects on surgical outcomes, cancer risk and economic outcomes.