My Trans-Parenting Journey: About Puberty Blockers
And the painfully long “pause” period
Not too long ago, we hit the one year mark of our thirteen year old transgender child being on puberty blockers. This season in the lives of trans youth is sometimes referred to as the “pause period,” because it’s quite literally like pressing a pause button.
Puberty blockers (or just ‘blockers’) are Gonadotropin-releasing hormone (GnRH) agonists used to temporarily inhibit or surpress puberty. Historically, blockers have been used in treating precocious puberty, but more recently, doctors have found them extremely beneficial in treating gender dysphoria in trans-identified youth.
Gender dysphoria, as defined in the DSM-V, is a condition in which a person has marked incongruence between their expressed or experienced gender and their biological sex assigned at birth, and causes clinically significant distress or impairment in social, occupational or other important areas of functioning. Typically, the onset of puberty worsens the emotional distress and anxiety of gender dysphoria in trans youth.
Simply put, puberty blockers present an option to put a pause on the development of unwanted secondary sexual characteristics in trans-identified youth until they are older. Further, blockers allow future trans men and trans women more time to explore and solidify their gender identity.
If a child desires blockers, is a candidate for them, and takes them but later decides not to transition to another gender, the effects of puberty blockers are immediately reversible by stopping the medication (i.e., without moving on to hormone treatments, puberty resumes normally).
In addition to providing the gift of time for trans youth, another function and benefit of puberty blockers is that they give the future trans person a more seamless fluidity in transitioning to their affirmed gender identity as an adult.
For trans youth in general, puberty blockers are one of the most important advances in the history of transition treatment. With the available intervention of fully reversible GnRH analogues to halt natural puberty in appropriately diagnosed adolescents, we can spare trans youth from the otherwise high frequency of mental health challenges they face when denied the chance to live authentically, including anxiety, depression, social isolation, self-harm, and drug and alcohol misuse, among others.
The decision to use puberty blockers is certainly no overnight decision. Mostly, a prescription for them is considered a life-saving measure, especially with more and more data becoming available showing us the same pattern: the alarmingly high rate of trans youth who attempt suicide, which is disproportionately higher than suicide attempts among youth who are cisgender, or ‘cis,’ (meaning their sex assigned at birth and their gender identity are in harmony).
Research released in October, 2018 by the American Academy of Pediatrics showed that among adolsecent groups, trans youth have the highest likelihood of attempting suicide when compared to their cisgender counterparts or opposites. Trans males (meaning assigned female at birth) reported the highest rate of attempted suicide, at 50.8%, whereas cisgender females accounted for just 17.6% of suicide attempts. Likewise, trans females (meaning assigned male at birth) had a 29.9% attempted suicide rate, whereas cis males accounted for just 9.8%.
For our child, being on blockers is the ultimate gift of time. It’s a period of time that allows her brain to mature a bit and see if this all still feels right after some time, without exacerbating her gender dysphoria with the arrival of unwanted secondary sex characteristics (which she has stated, in no uncertain terms, she does not want right now or any time soon). It buys her the time to consider — with the help of her gender therapist — whether she should go forward in the next series of steps towards transitioning to female, or stop the blockers altogether and resume male puberty. If blockers are halted, puberty resumes right where it left off, as if there had been no treatment.
Although they are considered critical and life-saving in many cases, blockers merely put a pause on puberty. Of course there is plenty of variance among individuals, but in our case, while on blockers our child is still continuing to grow just a tiny bit taller, and is still having the dreaded, typical adolescent mood swings. (Unfortunately, those don’t seem to stop, in case you were wondering, like I was.)
What does stop (temporarily) are all the things our child has been very vocal about not wanting to happen — the formation of an Adam’s apple and lowered vocal tone, facial hair growth, a more “square” look to the face and shoulders, a surge of testosterone, growth and maturation of all secondary sex characteristics, and so on.
This is where blockers can be life-saving for trans kids. With the arrival of puberty, most trans kids who have not taken puberty blockers become extremely depressed, or show signs of severe anxiety, because the development of secondary sex characteristics hits them unexpectedly like a sucker punch.
If you’re cis, remember how weird/uncomfortable/awkward the abrupt arrival of something like pubic hair seemed? Imagine that, but a thousand times worse, because it’s accompanied by an unexplainable, sudden onset of debilitating anxiety and crippling depression. Sometimes, those feelings are also in tandem with psychosomatic effects like severe, inescapable abdominal pain, or vomiting.
The onset of puberty has even been reported by some trans people as the first time gender dysphoria reared its ugly head, though this is more rare (and it’s something I’ve heard most often from older adults who say they always felt something was “wrong,” but didnt know they were transgender until well-into adulthood.)
Typically, gender dysphoria manifests in one way or another during childhood leading up to puberty. Regardless, puberty is typically the solidification of an undesired physical developmental process for those with a gender identity that is incongruent with their assigned sex at birth. And if a child was already clearly suffering from gender dysphoria, the onset of puberty can lead to a steady worsening of its symptoms.
Dr. Scott Leibowitz, head child and adolescent psychiatrist at the Ann & Robert H. Lurie Children’s Hospital of Chicago, says:
“If you are able to suspend puberty as soon as it happens you’re optimizing the benefits that it can bring physically.”
“That ability to blend in and be perceived as the gender that they identify with is associated with long-term psychological benefits,” says Leibowitz.
Certainly, acceptance and affirmation at home are the first steps in the overall well-being of a trans child. That said, children don’t grow up in a vacuum, so even children with supportive families may experience dysphoria. Nonetheless, families and doctors of transgender children report that the gender transition process is transformative, and often, life-saving.
Unfortunately, there are many misconceptions about puberty blockers (just as there are misconceptions about trans people). Understandably, the majority of people without trans kids or trans family members hold the most misconceptions. Like, that a kid can simply wake up one day and decide on a whim to change their gender. Or that a child would be doing all of this just “for attention,” or because they’re “acting out.”
Many folks also wrongly believe that if a child says they’re trans and visits their doctor, the doctor will just hand out puberty blockers like candy. Of course, this is a huge myth. In reality, it takes time (sometimes years) to get the process going, and involves a whole multidisciplinary support team comprised of child and family, medical providers, mental health therapists, and sometimes even lawyers.
Though the process of getting to the point where puberty blockers are needed varies a little among different people, doctors, and circumstances, for the most part it’s a similar path. For our child, in order to even get an appointment with an endocrinologist (a type of doctor who can administer blockers) we had to work with our child’s gender therapist for a long time.
That therapist had to show documentation that our child consistently and historically exhibited a pattern of gender dysphoria. *On that note, if your child is exhibiting signs that indicate it’s “more than just a phase,” I recommend that you start documenting everything. Save their drawings, or their writings from school, take photos, write your own notes from observations. Document things that stood out in conversations, include dates — anything you can hold onto, really, that helps support your child’s history and pattern of gender non-conformance, or gender dysphoria.
*It’s not absolutely necessary to do this, but I cannot recommend it highly enough. Because unfortunately, there are a slew of ignorant and transphobic people in society who accuse parents like me who are public advocates for trans kids of being “child abusers.” While this is nonsense (all credible, professional medical, psychological, psychiatric, etc. organizations overwhelmingly support affirmative care of trans youth), it never hurts to be able to prove your case.
Additionally, there are many cases of trans kids with parents who are divorced and have certain legal rights regarding their children, and there are many cases where one or both parents are not in agreement that their child is actually transgender. This is more often the case than not; I fully recognize that I am privileged, fortunate, blessed, lucky — whatever you want to call it — because my husband is 100% on board with actively raising a trans kid. However, both parents seeing eye to eye at the same time is the exception, not the norm.
Typically, there’s a case of one (or both) parents, as well as extended family members who are in denial (whether consciously aware of it or not) that their beloved child is transgender. They’re the ones who call it “a phase,” “a trend,” and say things like, “She’s only 8 years old, she doesn’t know what she wants to eat for breakfast, let alone, whether she feels a disconnect from her gender.”
Often, these folks are in denial because they’re confusing gender identity with sexual orientation, when the two things are completely separate, unrelated parts of an individual. While many people (not all) discover their sexual orientation during puberty, adolescence, or adulthood, research consistently shows that gender identity is solid by the age of 3, even if the child lacks the terminology to express what that is.
When our child decided she definitely wanted to “pause puberty” (and wanted to do it right away), to our relief, the therapist took over for a bit. Which was great because my husband and I were completely overwhelmed and in the dark about how this works. *For this reason, I cannot stress how important I believe it is to have an LGBT-friendly or trans-experienced therapist. It makes a huge difference.
Our child’s therapist has over twenty years experience working within the LGBT community, and has an endocrinologist she partners with specifically for trans youth. (Gender Clinics do basically the same thing.) Our child’s therapist was well-accustomed and able to do all the legwork of recommendations, exchanging notes and paperwork with the endocrinologist, the school system (when necessary), insurance, and submitting all necessary forms on our behalf. Again, this was a huge help for two cisgender parents.
Once our child was approved, we still had to wait a good three months before we could get the first appointment booked to consult with the endocrinologist and have our child’s initial examination and blood draw. After that appointment, it was even more waiting — waiting for the bloodwork to come back, waiting to hear the results, and waiting to correct anything that was a potential problem. In our child’s case, it was a simple Vitamin D deficiency that we could easily get under control.
Once the blockers get approved (meaning, the child, parent, and whole multidisciplinary support team are all in agreement this is the best option), sometimes there’s still a waiting process for the endocrinologist’s office to haggle with the insurance company to make sure you’re receiving the best option at the best price.
For our child, the endocrinologist recommended a regimen of leuprolide (Lupron) injections, which cost anywhere from $8,400 to $18,000 per year. Fortunately my husband’s company is progressive and inclusive, and his health insurance plan covers all aspects of trans care. But we’re lucky and extremely privileged in this way. Many people’s insurance plans don’t cover any trans care whatsoever. Or it takes a lot of dancing around and jumping through hoops between doctors and insurance to prove a medical necessity.
By the time our child received her first injection, she’d had lots of time to think about it, and still wanted to proceed. You must understand that for our anxiety-laden child, this is really saying a lot. Because this is a child who has such high anxiety over everything medical (whether it’s the dreadful flu shot, or having to swallow a simple, tiny pill), I thought there’d be absolutely no way our child would ever actually go through with this.
Especially given that whenever it’s blockers injection time, extensive bloodwork has to be drawn first. So it’s not just one-and-done with the needlework. And these injections are intramuscular, which hurt a lot more than your average run of the mill shot. Given all of these factors, I really didn’t think my child would be tolerant of any of this, regardless of how much she wanted to transition. Suffice it to say, I was surprised. Pleasantly surprised.
As I mentioned, we recently passed the one year anniversary of our child being on blockers — a pretty big deal, in my opinion. Not just because it’s the only commitment this child has ever cared to see through for this long, but because it just is. It’s a big deal on a number of levels.
For one thing, I don’t know when this “pause period” will end. That’s a huge unknown. I don’t like unknowns. I want contingency plans for my back-up plans. I want to know every possible scenario and what to plan for at every merge, turn, and exit.
But with this, I can’t. I have to let go of that need for control. All I know I can expect is that blockers aren’t typically given for longer than four to five years (so I still have a ways to go with this waiting thing).
And part of my job during this pause period is to pause everything, including resisting the temptation to pepper my child with questions and requests for updates.
Which is excruciatingly hard for me. Because I’m a type-A planner, and I care an awful lot about all the seemingly insignificant details. But with this, I can’t so much. I just have to let go and let it be. I have to trust the therapist is doing exactly what she needs to do, as are the doctors, and that they will immediately alert us when and if our child makes any other big decision.
I cannot adequately explain how difficult “the pause period” is. But to get through a year of this so far, successfully, on both my child’s part and my own (as well as my husband’s), is a tremendous hurdle in and of itself that I feel we’re successfully overcoming.
At the one year mark, another large blood panel was taken on my child, to see how her body was reacting after having received this intervention for a solid year. The doctor said they’d call to discuss the results. I don’t know why I was nervous or what I was even expecting to hear. But the call came during my work hours, so it went staight to voicemail. The message they left was short:
“Hi! It’s Karen from the endocrinologist’s office. I have the labs from your child. The doctor said the blood count and metabolic panel came back normal. She also said the Leuprolide is working as it should, as testosterone is less than ten, so this is good!”
She then gave a quick recommendation on the Vitamin D supplements, and the standard “feel free to call us back with any questions.”
And that was it.
The voicemail ended and I disconnected, oddly stunned, sitting in a state of temporary disorientation.
Again, I don’t know what I was expecting. Certainly no fanfare or congratulatory prize for making it through the one year mark of this pause on puberty. But receiving the message over a brief voicemail, like it was normal everyday business, a phone call they must make many times daily, it just felt so bittersweet. So peculiar. So, I don’t know… Distant? Cold? Sterile?
The juxtaposition of hearing “testosterone is less than 10, so this is good,” with my own knowledge that testosterone around this point for a typically developing male adolescent should be anywhere from 26–800 was an odd feeling to reconcile. It just felt so strange, and yet, so exactly right, all at the same time. Because my child is not a typically developing male, and I have to keep remembering that.
I know that in giving my child the gift of time we are perhaps saving her life. Not to mention, this is what our child wants, at least for now (and by “now” I mean going on at least ten years, and counting, growing stronger by the year so far). I know there are no guarantees for the future, and that this is the best thing to do right now. And yet, I feel somehow guilty, like I’m doing it all wrong — the way I think much of society would like me to believe — even though I know in my heart this is the right thing to do.
But you know what? This push and pull, back and forth — bittersweet triumph, extreme freedom, pride, and joy, mixed together with opposing forces like guilt and strong hesitation — is something that goes through my mind daily, sometimes hourly. I can just about guarantee this is the case with all parents of trans kids.
It’s not all rainbows and glitter and happy reality TV. Indeed, it is extremely beautiful to stand in awe of my child’s bravery, independence, and transformation. But I want to be real: All this joy mixed together with all this fear? This is what trans-parenting looks like, sounds like, feels like.
It’s scary. It’s unknown. You sometimes doubt your best instincts, which is all the more easy to do when people in your life — whether family or strangers — say transphobic things in your presence, intentional or unintentional. It’s all the more easy to doubt yourself when internet strangers accuse advocate parents like me of being child abusers (an accusation someone can only seriously make when they are totally ignorant of trans issues.)
Those with no experience trans-parenting are the ones most likely to think people like me are sharing our stories (i.e., baring our souls) for some “five minutes of fame” rather than the real reason — we’re sharing our journeys so that other families going through the same thing will know they aren’t alone. Many of us are led to public advocacy because someone before us was brave enough to do it first and thus, gave us the courage we needed to step up and be better parents and advocates.
When we’re given careless labels like “child abuser” for allowing our trans kids to socially transition, pause puberty, or transition further, all of us in the trans-parenting circle — which is huge — know that nothing could be further from the truth. But when the critics sometimes amp up my worst fears and get me down, I try to shift my mindset and remind myself of this:
Our trans children aren’t transitioning so much as they are growing into exactly who they were always meant to be.
It is more us, as parents and families, who have a bigger transition to undergo — to unlearn fixed mindsets, old pronouns and “dead names,” to reconcile the overwhelming guilt that tries to tell us we did something wrong, to push aside our expectations of how we thought our child’s life would look and feel and be, to stand tall in the face of our own worst fears, to go out into all of the people every day and face judgment which isn’t always kind, to let go.
As advocates, we’re meeting with teachers and administrators, coaches, club leaders, front office professionals, doctors, mental health providers, and even parents of our kids’ friends who just want our kids to have a sleepover.
It’s us parents of trans kids who are having to “out” ourselves and our children time and again, because no matter how much we dislike it, gender is public. We find ourselves advocating for rights we’d never considered, fighting for things our kids need that we never imagined we’d have to fight for, and we find ourselves learning real fast who our real friends are and are not.
Raising a trans kid, especially when you get to the point where they’re transitioning beyond the social aspects of name and pronoun change, when you’ve ventured from letting them dress in line with their gender identity to the point where you’re allowing them to take puberty blockers, is not for the faint of heart. This work may be the highest, most mature, healthiest form of what it means for a parent to let go. It’s the ultimate gesture of unconditional love. Yes, it’s scary. But it’s also the most rewarding thing trans-parents can do — for both ourselves and our children. And of course, for greater society.
Martie sir-ROY (she/her) writes social commentary on a variety of topics and has been a featured contributor for Medium, HuffPost, Scary Mommy, NPR affiliates, and SiriusXM Insight, among others. She is the founder of S.E.A.R.CH., a program at her local LGBT Center that serves the needs of trans & gender nonconforming youth and their parents. Connect with her on Twitter or Facebook.