**โ**
**(Please note that we've defaulted to the British English spellings of oestrogen and oestradiol instead of estrogen and estradiol, as this issue affects those in the UK. In general, we use and prefer the versions without the leading silent O.**
**Also, GnRH means gonadotropin-releasing hormone. You'll see us writing it a lot followed by "analogue", "agonist" or "antagonist". Those are all types of "puberty blockers.)"**
**โ**#
Original puberty blockers banBack on 2024-05-31, we wrote a post in response to the transphobic [emergency restrictions for new prescriptions of puberty blockers to trans youth](
GOV.UK
New restrictions on puberty blockers
New regulations restrict the prescribing and supply of puberty-suppressing hormones to children and young people under 18.
) by the then health minister.
[Our original post explaining that in more detail can be found here](
The Cult of Shiv
SleepyCatten (@SleepyCatten@cultofshiv.wtf)
Content warning: Helpful tips for supportive parents of trans kids in the UK, in light of the ban on new prescriptions of puberty blockers
), but we have now unpinned it and replaced it with this post to ensure everyone has the most up-to-date info.
**โ**#
New government hopes dashedIt was hoped that the new government would **not** extend the ban, but as soon as they announced [Wes "Weasel" Streeting](
Wes Streeting - Wikipedia
) (a highly vocal transphobe) as the new [Health Secretary](
Secretary of State for Health and Social Care - GOV.UK
), he pretty much immediately announced his intention to extend the temporary ban, [with an aim to making it permanent](
https://x.com/JolyonMaugham/status/1811670898740490413 ).
Per [this post by TransActual](
Statement on the extended ban on puberty blockers – TransActual
), it's not like Weasel and his advisors weren't made aware of all the negative impacts an extension would have, as **"he was told about it when meeting with the representatives of LGBTQ+ organisations".**
Even more darkly-farcical is that the justification Weasel used for continuing the targeted medical discrimination against trans youth is that it's being done **"to avoid serious danger to health"**, which is not only contrary to the information provided by those LGBTQ+ organisations, but completely contrary to:<li><a href="
https://transactual.org.uk/advocacy/critiques-of-the-cass-review/" target="_blank" rel="nofollow noopener noreferrer">increasing international condemnation of the Cass Review</a>, which was the primary justification for the order;</li><li><strong>all</strong> valid scientific studies over decades, which were excluded by the Cass Review because they weren't <strong>"double blinded controlled studies"</strong> (which is medically unethical);</li><li>even the frickin' <a href="
https://www.bma.org.uk/bma-media-centre/bma-to-undertake-an-evaluation-of-the-cass-review-on-gender-identity-services-for-children-and-young-people" target="_blank" rel="nofollow noopener noreferrer">BMA criticising and planning to review the Cass Review</a>.</li>
It's not that Weasel doesn't understand this: it's that he either doesn't care or actively wants to hurt trans youth by making it as difficult as possible for them to medically transition :PleadingFace: ๐
**โ**#
The temporary ban extension explainedThe news page on on the government is coldly entitled [Puberty blockers temporary ban extended](
GOV.UK
Puberty blockers temporary ban extended
Temporary ban on prescription and supply of puberty blockers extended.
), as if it's no big deal. It links to [the original ban](
GOV.UK
New restrictions on puberty blockers
New regulations restrict the prescribing and supply of puberty-suppressing hormones to children and young people under 18.
) and to the new-and-worsened ["The Medicines (Gonadotrophin-Releasing Hormone Analogues) (Emergency Prohibition) (Extension) Order 2024"](
The Medicines (Gonadotrophin-Releasing Hormone Analogues) (Emergency Prohibition) (Extension) Order 2024
This Order prohibits, subject to exceptions, the retail sale, and the supply in circumstances corresponding to retail sale, of medicinal products t...
) that's replacing it.
This order extends the duration of the original ban until 2024-11-26, but also increases its scope. The original order did not apply to Northern Ireland and allowed EU professionals to prescribe. This small loophole gave a glimmer of hope for supportive parents of trans youth, who could essentially:<li>Get a prescription via a private online gender service from an EU medical professional.</li><li>Travel to Northern Ireland to pick up the prescription.</li><li>Travel back home to use it to support their trans kid.</li>
The government clearly discovered this, as the new order has 2 very clear statements on the news page:
> It also prevents the sale and supply of the medicines from prescribers registered in the European Economic Area or Switzerland for any purposes to those under 18.
> The government has also extended the order to cover Northern Ireland, following agreement from the Northern Ireland Executive, to come into effect from 27 August 2024.
> **โ**#
And now for the good news ๐ฅฐ##
GnRH antagonistsWeasel isn't as smart as he thinks he is. Under [Article 2](
The Medicines (Gonadotrophin-Releasing Hormone Analogues) (Emergency Prohibition) (Extension) Order 2024
This Order prohibits, subject to exceptions, the retail sale, and the supply in circumstances corresponding to retail sale, of medicinal products t...
), they've once again defined GnRH analogues as:
> a medicinal product that consists of or contains buserelin, gonadorelin, goserelin, leuprorelin acetate, nafarelin or triptorelin
Whilst technically calling them analogues isn't incorrect, all of the medications listed above are actually [GnRH agonists](
Gonadotropin-releasing hormone agonist - Wikipedia
).
Just like the original order, they've ignored [GnRH antagonists](
Gonadotropin-releasing hormone antagonist - Wikipedia
), as these don't tend to be typically used, despite being just as safe and effective, with the same low-risk profile.
The wiki page on GnRH antagonists even specifically states in the [Other uses section](
Gonadotropin-releasing hormone antagonist - Wikipedia
):
> GnRH antagonists could be used as puberty blockers in transgender youth and to suppress sex hormone levels in transgender adolescents and adults, but have not been studied in this context.
We've checked through the list of GnRH antagonists listed on [NICE](
NICE website: The National Institute for Health and Care Excellence
Homepage
NICE helps practitioners and commissioners get the best care to patients, fast, while ensuring value for the taxpayer
) ("National Institute for Health and Care Excellence") as being able to be prescribed, and the following ones could be legally prescribed by any willing UK medical professional without infringing on the order:<li>Cetrorelix (<a href="
https://en.wikipedia.org/wiki/Cetrorelix" target="_blank" rel="nofollow noopener noreferrer">Wiki</a>) (<a href="
https://bnf.nice.org.uk/drugs/cetrorelix/" target="_blank" rel="nofollow noopener noreferrer">NICE</a>) (<a href="
https://www.medicines.org.uk/emc/product/1605" target="_blank" rel="nofollow noopener noreferrer">EMC</a>)</li><li>Degarelix (<a href="
https://en.wikipedia.org/wiki/Degarelix" target="_blank" rel="nofollow noopener noreferrer">Wiki</a>) (<a href="
https://bnf.nice.org.uk/drugs/degarelix/" target="_blank" rel="nofollow noopener noreferrer">NICE</a>) (<a href="
https://www.medicines.org.uk/emc/search?q=%22degarelix+acetate%22" target="_blank" rel="nofollow noopener noreferrer">EMC</a>)</li><li>Ganirelix (<a href="
https://en.wikipedia.org/wiki/Ganirelix" target="_blank" rel="nofollow noopener noreferrer">Wiki</a>) (<a href="
https://bnf.nice.org.uk/drugs/ganirelix/" target="_blank" rel="nofollow noopener noreferrer">NICE</a>) (<a href="
https://www.medicines.org.uk/emc/search?q=%22ganirelix+acetate%22" target="_blank" rel="nofollow noopener noreferrer">EMC</a>)</li><li>Relugolix (<a href="
https://en.wikipedia.org/wiki/Relugolix" target="_blank" rel="nofollow noopener noreferrer">Wiki</a>) (<a href="
https://bnf.nice.org.uk/drugs/relugolix/" target="_blank" rel="nofollow noopener noreferrer">NICE</a>) (<a href="
https://bnf.nice.org.uk/drugs/relugolix/medicinal-forms/#oral-tablet" target="_blank" rel="nofollow noopener noreferrer">No EMC page, but NICE has some details here</a>)</li>
The drugs would be being used off-label, but so are **all** the existing meds for trans people anyway! There are no officially-licensed medications for trans people in the UK. It's all outside of their prescription guidelines.
We actually had to sign 2 consent forms to request HRT, 1 of which genuinely reads:
> I confirm I understand feminising hormones are not licenced for the treatment of Gender lncongruence; however, I am happy to receive this treatment.
That's not an outdated form either. It's what we had to return to the [East of England Gender Service (EOEGS)](
Transgender
East of England Service
The Nottingham Centre for Transgender Health Network (NCTH) launched a
new national pilot, the East of England Gender Service, in June 2021 for
peo...
) in May 2024.
**โ**##
Alternatives to puberty blockersWhilst puberty blockers are considered the gold standard:<li>They were mainly offered in place of gender-affirming hormone therapy in order to delay the medical transition of trans kids, in the hopes that they could be "persuaded" that they're not actually trans (i.e., conversion therapy).</li><li>Other alternatives to these do exist and are commonly available.</li>###
Anti-androgens (steroidal and non-steroidal)For those who want to block testosterone, the other options are broadly [steroidal anti-androgens](
Steroidal antiandrogen - Wikipedia
) or [non-steroidal anti-androgens](
Nonsteroidal antiandrogen - Wikipedia
). They're typically grouped together under [anti-androgens](
).
Of these, the prescribable options are:<li><a href="
https://en.wikipedia.org/wiki/Spironolactone" target="_blank" rel="nofollow noopener noreferrer">spironolactone</a> (<a href="
https://bnf.nice.org.uk/drugs/spironolactone/" target="_blank" rel="nofollow noopener noreferrer">NICE</a>)</li><li><a href="
https://en.wikipedia.org/wiki/Cyproterone_acetate" target="_blank" rel="nofollow noopener noreferrer">cyproterone acetate</a> (<a href="
https://bnf.nice.org.uk/drugs/cyproterone-acetate/" target="_blank" rel="nofollow noopener noreferrer">NICE</a>)</li><li><a href="
https://en.wikipedia.org/wiki/Bicalutamide" target="_blank" rel="nofollow noopener noreferrer">bicalutamide</a> (<a href="
https://bnf.nice.org.uk/drugs/bicalutamide/" target="_blank" rel="nofollow noopener noreferrer">NICE</a>)</li>
Why no mention of [5-alpha-reductase inhibitors](
5ฮฑ-Reductase inhibitor - Wikipedia
) like [finasteride](
) or dutasteride? Because all they do is reduce the conversion of testosterone into [dihydrotestosterone (DHT)](
Dihydrotestosterone - Wikipedia
). They're technically considered anti-androgens, but both have some pretty common side effects, haven't been shown to be effective for trans healthcare, and interaction badly with micronised progesterone.####
SpironolactoneSpironolactone has tonnes of common, negative side effects and is a weak anti-androgen at best. The fact that it's still even prescribed to trans people to block testosterone is probably solely because it's cheap. Even its Wiki page states:
> Its use continues despite the rise of various accessible alternatives such as bicalutamide and cyproterone acetate with more precise action and less side effects.####
Cyproterone acetateCyproterone acetate, even at low daily doses (6.25-12.5 mg), isn't particular great either. It's a [progestin](
Progestogen (medication) - Wikipedia
) (a synthetic [progestogen](
Progestogen (medication) - Wikipedia
)), has a fair number of common side effects, and can cause liver issues.
The only safe progestogen for feminising HRT is [bioidentical micronised progesterone](
https://en.wikipedia.org/wiki/Progesterone_(medication)#Transgender_women ). It's best to avoid progestins at all costs, due to their inherent risks.####
BicalutamideNow we come to the oft-overlooked and demonised bicalutamide, even though one of its key uses, as listed on its wiki page, is:
> as a puberty blocker and component of feminizing hormone therapy for transgender girls and women
It works in a different way to other anti-androgens. It actually increases testosterone production slightly, but then converts the excess into [oestradiol (E2)](
) and blocks [androgen receptors](
Androgen receptor - Wikipedia
). It's kind of an invisible blocker, as any blood tests will show a higher testosterone level, but androgenic effects will stop, due to the blocked receptors.
Its common side-effects are actually positive effects for many seeking feminisation (e.g., breast growth; decreased libido; reduced body hair growth) alongside blocking androgen receptors. This is, however, worth taking into consideration for someone who may want to block androgenic effects, but not particularly feminise, as this would not be best for them.
Bicalutamide **does** have a common chance of raising liver enzymes, so it's absolutely **vital** to monitor closely and get regular [liver function blood tests](
Liver function tests - Wikipedia
).
Why vital? Because seeing **elevated** liver enzymes is an indicator of liver cells breaking down at an unusual rate, which can be an early warning sign of [liver toxicity (toxic hepatitis)](
). Further tests can then be run to confirm.
The liver is very capable organ in terms of [recovery and regeneration](
Liver regeneration - Wikipedia
), so stopping bicalutamide early if further tests are positive for liver toxicity will stop further damage and increase the likelihood of the liver repairing any slight damage caused.
And now we come to the reason why it's not more-commonly used: there have been [10 published case reports of liver toxicity](
) reported to the [FDA Adverse Event Reporting System (FAERS)](
FDA Adverse Event Reporting System - Wikipedia
) in the USA, from which there were 2 deaths. As far as we can tell from reading the links into this, none of these were trans people (of any age) taking a low daily dose of 25-50 mg.
In other words, the **fear** of bicalutamide is **disproportionate** to the **actual real-world risk**, especially for trans patients taking low doses.
This is what the [bicalutamide comparison section](
) has to say:
> The side effect profile of bicalutamide in men and women differs from that of other antiandrogens and is considered favorable in comparison....Relative to GnRH analogues and the steroidal antiandrogen (SAA) cyproterone acetate (CPA), bicalutamide monotherapy has a much lower incidence and severity of hot flashes and sexual dysfunction.... In addition, unlike GnRH analogues and CPA, bicalutamide monotherapy is not associated with decreased bone mineral density or osteoporosis.
Bicalutamide is the best alternative for most, but not all, trans youths wishing to block testosterone and achieve some bonus feminisation before being prescribed oestradiol. It has a lower risk profile overall than cyproterone acetate, but due to extremely rare risks of liver toxicity and lung diseases, many medical practitioners won't prescribe it ๐###
Anti-oestrogensThere are [anti-oestrogens](
), particularly [SERMs](
Selective estrogen receptor modulator - Wikipedia
), but they typically have a lot of side effects and risks. As a rule, most don't come highly recommended.
We wish we could be more positive about them here, but we wouldn't recommend any of them for anyone wishing to block oestrogen production or an oestrogenic puberty.
Look to the GnRH antagonists that aren't blocked (like relugolix), or consider the option below. ###
MonotherapyIt's very notable that the extended ban still does **not** ban any oestradiol (oestrogen) or testosterone prescriptions.
This means that there is **still** nothing to stop supportive parents from helping their trans kids to get a private prescription for oestradiol or testosterone.
Furthermore, due to the way human bodies work, if you maintain a high-enough trough (lowest) level of either oestradiol or testosterone, the body will basically tell the gonads to stop producing that hormone. (We know there's a term for this, but we cannot remember what it is.)
**Please note that the figures quoted below are the typical figures for trans adults. Even [WPATH SOC8](
WPATH
SOC8 Chapters - WPATH
) seems to have no defined ranges for trans youth, just same vague dosage suggestions adapted from the [Endocrine Society Guidelines](
Gender Dysphoria/Gender Incongruence Guideline Resources
The 2017 Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons is an update to the 2009 version, which establishes and standardizes th...
) under "Appendix C GENDER-AFFIRMING HORMONAL TREATMENTS" within "Table 3".**
For feminising HRT in adults, monotherapy typically requires maintaining an oestradiol trough of around 750 pmol/L. It varies from person to person, so some folks might need as little as 350 pmol/L.
You'll know if their oestradiol trough is sufficient if their testosterone level is 2.4 nmol/L or lower, though up to 3 nmol/L is still considered within the high-end of female range.
For masculinising HRT in adults, a testosterone trough of around 10-12 nmol/L is generally considered the aim when using prescription testosterone medications like [Nebido 1000 mg / 4 mL](
Nebido 1000 mg/4 ml solution for injection - Summary of Product Characteristics (SmPC) - (emc) | 14631
Nebido 1000 mg/4 ml solution for injection - Summary of Product Characteristics (SmPC) by Grunenthal Ltd
) or [Sustanon 250 mg/mL](
Sustanon 250, 250mg/ml solution for injection - Summary of Product Characteristics (SmPC) - (emc) | 5373
Sustanon 250, 250mg/ml solution for injection - Summary of Product Characteristics (SmPC) by Aspen
), with a peak of around 25-30 nmol/L.
You'll typically know if their testosterone trough is sufficient if their oestradiol level is under 150 pmol/L, though some folks may be up to around 180 pmol/L.
Monotherapy completely avoids the need for any kind of puberty blocker, anti-androgen, or anti-oestrogen.
It also has the delightful side-effect of making your trans kid happy to be starting the puberty that they want to go through sooner, thus alleviating their feelings of gender dysphoria and allowing them to enjoy their lives, rather than continuing to wait on non-existent NHS healthcare.
With feminising HRT, monotherapy is most easily achieved by a daily high-dose of oestradiol in the form of oestrogel (oestrogen gel) applied to a high-absorption area, but could in theory be achieved by sufficient patches applied twice weekly. Injections are sadly not available on prescription, and implants will be very, very expensive and only privately prescribed.
For masculinising HRT, monotherapy can be easily achieved by daily application of testosterone gel or cream, but is more easily achieved by testosterone injections (Nebido or Sustanon). However, the injection recommendations are all for adults, so these may be harder to adjust.
For trans adults, [NHS trans masc shared care guidelines](
๐.pdf ) are typically Nebido 1000 mg every 12 weeks (after an initial loading period of 1 injection every 6 weeks for the first 12 week period).
For Sustanon 250 mg, those guidelines are far less clear. It suggests every 1 injection every 4 weeks, but seems to imply a loading dose possibly too in order to suppress menstruation, but it's really not explained well.
**โ**##
Blood testsThese can be done privately, completely avoiding the need for the NHS.
You can find more information here:<li><a href="
https://genderkit.org.uk/resources/blood-testing/" target="_blank" rel="nofollow noopener noreferrer" translate="no"><span class="invisible">
https://</span><span class="ellipsis">genderkit.org.uk/resources/blo</span><span class="invisible">od-testing/</span></a></li><li><a href="
https://transactual.org.uk/medical-transition/hormone-therapy/" target="_blank" rel="nofollow noopener noreferrer" translate="no"><span class="invisible">
https://</span><span class="ellipsis">transactual.org.uk/medical-tra</span><span class="invisible">nsition/hormone-therapy/</span></a><strong>โ</strong></li>##
Where can we find more information about gender-affirming care by experts who actually want to help trans kids?Although far from perfect, arguably the best sources currently are:<li><a href="
https://www.tandfonline.com/doi/pdf/10.1080/26895269.2022.2100644" target="_blank" rel="nofollow noopener noreferrer">WPATH Standards Of Care 8</a></li><li><a href="
https://transcare.ucsf.edu/guidelines" target="_blank" rel="nofollow noopener noreferrer">UCSF guidelines for gender-affirming care</a><strong>โ</strong></li>##
What if I'm still confused about all this?Ask for help. We're all in this together. Some of us know a **lot** about how broken trans healthcare is on the NHS right now, not just for trans kids but for trans adults too.
The key thing to remember is that you are **never** alone. All you have to do is reach out and ask for help from the community :TransHeart:โ :HeartHands:
Here is a non-exhaustive list of organisations who may be able to offer you some immediate support:<li><a href="
https://mermaidsuk.org.uk/" target="_blank" rel="nofollow noopener noreferrer">Mermaids</a></li><li><a href="
https://mermaidsuk.org.uk/" target="_blank" rel="nofollow noopener noreferrer">Gendered Intelligence</a></li><li><a href="
https://switchboard.lgbt/" target="_blank" rel="nofollow noopener noreferrer">Switchboard National LGBTQIA+ Support Line</a></li>
You can find more info resources and support on [this Gender Construction Kit page](
Gender Construction Kit
Information for families - Gender Construction Kit
Helpful organisations and publications in the UK for people with trans, nonbinary, and gender non-conforming family members and partners
).
And here are some other websites / people you may want to look up:<li><a href="
https://transkidsdeservebetter.org/" target="_blank" rel="nofollow noopener noreferrer">Trans Kids Deserve Better</a></li><li><a href="
https://www.instagram.com/transkidsdeservetogrowup/" target="_blank" rel="nofollow noopener noreferrer">Trans Kids Deserve To Grow Up</a></li><li><a href="
https://linktr.ee/soft__limit" target="_blank" rel="nofollow noopener noreferrer">Dee Whitnell (Founder of TransKidsDeservetoGrowUp)</a></li><li><a href="
https://www.wearequeeraf.com/" target="_blank" rel="nofollow noopener noreferrer">Queer AF</a></li><li><a href="
https://www.linkedin.com/in/nancy-kelley-86287730/" target="_blank" rel="nofollow noopener noreferrer">Nancy Kelley (Executive Director of DIVA Magazine)</a> and <a href="
https://diva-magazine.com/2024/08/23/trans-kids-deserve-better-responds-to-the-ban-on-puberty-blockers/" target="_blank" rel="nofollow noopener noreferrer">big supporter of trans youth</a></li><li><a href="
https://www.anne.health/" target="_blank" rel="nofollow noopener noreferrer">Anne (aka Anne Health Limited)</a>, which has a <a href="
https://www.anne.health/helpline" target="_blank" rel="nofollow noopener noreferrer">helpline</a> and offers trans+ gender-affirming healthcare</li><li><a href="
https://transcare.ucsf.edu/guidelines" target="_blank" rel="nofollow noopener noreferrer">UCSF guidelines for gender-affirming care</a><strong>โ</strong></li>
**Edits:** Apologies for all the typos. We're trying to gradually get rid of them all ๐
Further apologies for the minor formatting edits as we notice issues.
#TransKidsMatter #TransYouthAreLoved #TransKidsDeserveToGrowUp #TransKidsDeserveToThrive #TransKids #ProtectTransKids #trans #transgender #enby #NonBinary #agender #genderfluid #genderqueer #transition #TransLiberationNow #TransRightsAreHumanRights #TransRights #queer #LGBTQ+ #LGBTQIA+ #PubertyBlockers #GnRHAgonists #GnRHAntagonists #GnRHAnalogues #AntiAndrogens #AntiEstrogens #AntiOestrogens #SERM #spironolactone #CyproteroneAcetate #bicalutamide
