To treat or not to treat: puberty suppression in childhood-onset gender dysphoria

Key Points

  • Puberty suppression using gonadotropin-releasing hormone analogues is prescribed to relieve the distress associated with pubertal development in adolescents with gender dysphoria, in order to provide time for further exploration

  • Treating prepubertal individuals with gender dysphoria is particularly controversial owing to their unstable pattern of gender variance compared with gender-dysphoric adolescents and adults

  • The absence of robust data in support of or against the use of puberty suppression in childhood-onset gender dysphoria has led to inconsistencies between health-care pathways across different centres

  • The paucity of evidence of the effect of puberty suppression on health-related outcome measures calls for studies that might help to advance the evidence-based debate on risks and benefits

  • Despite a limited number of studies, the existing literature supports puberty suppression as an early, sufficiently safe, and preventive treatment for gender dysphoria in childhood and adolescence


Puberty suppression using gonadotropin-releasing-hormone analogues (GnRHa) has become increasingly accepted as an intervention during the early stages of puberty (Tanner stage 2–3) in individuals with clear signs of childhood-onset gender dysphoria. However, lowering the age threshold for using medical intervention for children with gender dysphoria is still a matter of contention, and is more controversial than treating the condition in adolescents and adults, as children with gender dysphoria are more likely to express an unstable pattern of gender variance. Furthermore, concerns have been expressed regarding the risks of puberty suppression, which are poorly understood, and the child's ability to make decisions and provide informed consent. However, even if the limited data available mean that it is not possible to make a conclusive treatment recommendation, some safety criteria for puberty suppression can be identified and applied.

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Figure 1: Puberty suppression.


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Authors would like to thank all patients and colleagues met during their years of clinical research activity. A special thank goes to the Gender Unit at the University of Bari, Italy, and the Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust, United Kingdom.

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R.C. and M.C. researched data for the article, and wrote the manuscript. All authors made substantial contributions to discussions of content and reviewed and edited the manuscript before submission.

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Correspondence to Rosalia Costa.

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The authors declare no competing financial interests.

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Costa, R., Carmichael, P. & Colizzi, M. To treat or not to treat: puberty suppression in childhood-onset gender dysphoria. Nat Rev Urol 13, 456–462 (2016).

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