Do you need to take puberty blockers to be eligible for gender affirmation surgery? 

According to plastic and reconstructive surgeon Dr David Sharp, the short answer to this question is no. But gender affirming care in Queensland just became more complicated, with the new Queensland Government unexpectedly announcing the suspension and review of puberty blocking treatments. It has left many transgender young people, their care teams and loved ones wondering how this may impact their ability to access gender confirmation surgery in the future. These medications have long served as a crucial intervention for transgender adolescents, offering them time to explore their gender identity before the irreversible changes of puberty occur. In this article, Dr Sharp answers some commonly asked questions relating to gender affirming care, puberty blockers and transgender surgery.

Transition-related care includes hormonal therapy, mental health care and gender-affirming surgery. While the politicisation of transgender healthcare has played out recently in other countries, Australian doctors have enjoyed a progressive and clinician-led approach that aims to provide evidence-based, well-informed healthcare options for trans patients. This has included the use of puberty blocking medications in early adolescence, followed by surgery to alter the appearance of secondary sexual characteristics, such as breasts. Our clinic has been part of the gender-affirming care model for almost a decade, giving us extensive experience in chest surgery for trans men and women.

Gender identity is a person’s internal sense of being male, female, neither, or a combination of genders. Gender dysphoria can occur when distress arises from a difference between gender identity and sex assigned at birth or physical sex characteristics. For transgender and gender-diverse young people with gender dysphoria, delaying puberty may support mental wellbeing, ease anxiety or depression, improve social confidence, reduce future surgical needs, and lower self-harm risk. However, puberty blockers alone may not fully relieve gender dysphoria and are usually considered part of broader medical and psychological care.

For individuals transitioning from female-to-male or male-to-female, chest surgery can play a vital role in aligning physical appearance with their gender identity. The timing of hormonal interventions can affect chest tissue development, which may factor into their surgical results. Through breast removal – also known as mastectomy, TOP or FTM (female-to-male) surgery – for transgender men, as well as breast augmentation for transgender women, we have observed the impact of gender affirming healthcare at the grassroots level.

Gender affirmation is multidisciplinary treatment in which general practitioners, endocrinologists, mental healthcare providers and surgeons play an important role. Comprehensive support from multidisciplinary teams ensures that patient receives care tailored to their unique needs. This article specifically relates to plastic surgery for patients navigating these uncertainties. Dr Sharp’s goal is to empower transgender individuals with reliable information as they plan their journey towards gender affirmation.

What is Puberty Blocking Hormone Therapy?

Puberty blocking hormone therapy is a recognised, reversible, treatment option for transgender adolescents, designed to delay the physical changes of puberty. The medicines most often used for this purpose are called gonadotropin-releasing hormone (GnRH) analogues.

This medical intervention provides young people with additional time to explore their gender identity before irreversible secondary sexual characteristics develop. In Australia, it has been an important step in the gender affirmation process, allowing for a smoother transition should they choose to pursue further surgical interventions in the future. Studies, such as this one which surveyed 220 youths receiving puberty blockers and their parents, reported very high levels of satisfaction. However, clinicians emphasise that this therapy is not without its considerations, risk and potential side effects, such as fertility, bone growth and density.  

What Effect Do Puberty Blockers Have On Future Chest Surgery?

The most important message here is that a patient does not need to have puberty blocking treatment in order to be eligible for breast removal or augmentation surgery in the future – but it may simplify the surgery by delaying the onset of unwanted pubertal changes and preserving chest tissue in a more ‘neutral’ state. This can reduce the complexity of surgery, potentially leading to improved cosmetic outcomes and more straightforward surgical recovery. A 2019 study of 300 individuals found that when puberty suppression occurred earlier in development, “mastectomy was more frequently omitted or less invasive” (van de Grift et al., 2020).

Is There an Impact on Chest Surgery, for Female-to-Male Transitions?

For individuals transitioning from female to male, in our practice, TOP surgery typically involves a bilateral mastectomy with free nipple grafting.

The preservation of a more ‘pre-pubertal’ breast tissue composition through the use of puberty blockers can result in less tissue and skin needing to be removed during surgery, potentially allowing for a more predictable contour, less complex recovery and reduced scarring. Hormone therapy can also produce chest hair and facial characteristics more aligned with stereotypical male aesthetic traits. Each patient’s anatomy is unique, and the commencement of hormone therapy is only one factor in surgical decision making. It remains essential for patients to have thorough discussions with their medical, mental healthcare and surgical team to understand how their medical history – including hormone therapy – might influence surgical outcomes.

Is There an Impact on Chest Surgery, for Male-to-Female Transitions?

For those transitioning from male to female, chest surgery generally involves breast augmentation using implants. Puberty blockers may contribute to a more standardised baseline in chest development, such as chest wall and pectoral muscle size, possibly making the transition to a more feminine chest appearance smoother once the appropriate hormone regimen is initiated. Puberty blocking medication can also reduce the development of typically masculine facial characteristics, such as a more prominent jawline, brow and nose. In some cases where trans women want a more feminine facial appearance, this may mean that they can avoid facial plastic surgery to  Nonetheless, the potential alteration in chest tissue quality and volume means that surgeons must carefully assess each case to ensure that implant selection and placement are suited to the individual’s unique anatomy. Tailored surgical planning remains crucial to achieving the desired aesthetic results and confirming gender identity effectively.

The Queensland Government Review and Future Implications

The recent announcement by the Queensland government to suspend and review the administration of puberty blocking medications has prompted important discussions among healthcare professionals and patients alike. While this review may introduce some uncertainty regarding the timing and administration of puberty blockers, its impact on future chest surgery is likely to be nuanced. For patients considering either bilateral mastectomy or breast augmentation, it is important to stay informed and consult with an experienced surgeon. Dialogue between endocrinologists, mental health professionals and surgical teams will be essential to navigating these changes and ensuring optimal patient outcomes. For further insights into the evolving landscape of gender-affirming care, additional peer-reviewed research is available.

Gender Affirmation Care and Patient Outcomes

While more research is needed in this space, existing studies consistently demonstrate the benefits of gender affirming care.  Transgender Australians experience markedly higher rates of suicide compared to the general population, with a survey conducted by the National LGBTI Health Alliance in 2017 finding that 40–50% of transgender respondents had attempted suicide at some point in their lives, vs 3-4% for the general Australian population according to estimates based on data from the Australian Bureau of Statistics. While these figures can vary depending on the study design, sample size and methods, the disparity is clear and has been observed across multiple studies. A Latrobe University Study found that trans and gender diverse young people who access hormone therapies experience significant reductions in suicide risk, distress and mental health issues. When this care is withheld, the risk of suicide increases 15-fold compared to their cisgender peers:

“Trans and gender diverse youth who are supported to affirm their gender in ways that are meaningful to them, whether medically, legally or socially, had considerably better wellbeing outcomes. Feeling supported to affirm their gender resulted in less suicidality, less mental health concerns and greater happiness. Those who felt supported to affirm their gender were also less likely to experience homelessness and less likely to be subject to verbal harassment in the past 12 months.”

The elevated risk among transgender Australians is often attributed to the high levels of discrimination, stigma and barriers to accessing appropriate mental health care that many in the community face. This stark difference highlights the urgent need for targeted mental health support and inclusive services that address the unique challenges experienced by transgender individuals.Research – such as this study of 3,134 patients – showed that gender affirming surgery can reduce antidepressant use, depression, anxiety, suicide attempts and alcohol/drug misuse. Several studies have found that many transgender individuals experience improvements in mental health, including reductions in suicidal ideation and suicide attempts, following gender confirmation surgery. For many, the surgery alleviates gender dysphoria, enhances body satisfaction, and leads to a better overall quality of life. These improvements are believed to contribute to the observed decreases in suicidality post-surgery. For instance, a systematic review by Murad et al. (2010) reported that gender affirmation interventions were associated with significant reductions in suicide attempts and improvements in psychological functioning over time.

However, it is important to note that while many studies support this positive association, the relationship between gender confirmation surgery and suicide rates is complex. Outcomes may vary based on factors such as pre-existing mental health conditions, levels of social support, access to comprehensive post-operative care, and broader societal acceptance. Not all individuals experience the same level of benefit from surgery alone, and continued mental health support remains a critical component of care for many transgender people.

Further longitudinal research is needed to fully understand the extent and durability of these improvements. Nonetheless, current evidence suggests that gender confirmation surgery can play an important role in reducing suicidality for many transgender individuals when combined with comprehensive, multidisciplinary care.

A recent systematic review and meta-analysis concluded that approximately 80% reported subjective improvement in terms of gender dysphoria, quality of life, and psychological symptoms, but also that there are studies reporting high psychiatric morbidity and suicide rates after sex reassignment. The authors concluded though that the evidence base for sex reassignment “is of very low quality due to the serious methodological limitations of included studies.”

What Are The Preoperative Requirements For Chest Surgery?

This may vary between clinics, and so we recommend reaching out to your practice of choice to find out more about their specific requirements. In our clinic, patients obtain a referral from their general practitioner, as well as a letter of support from their treating psychologist, psychiatrist or specialist gender clinic outlining the process they have undergone before making this decision (including both physical and mental preparations), their suitability for surgery and the postoperative psychological and social supports that they will have in place. The preoperative process includes multiple consultations to assess the patient’s readiness for surgery, and their understanding of the procedure and its outcomes, risks and recovery requirements. While many patients have undergone hormone therapy prior to surgery, it is not essential.

This article is intended to provide medically informed insights for transgender individuals considering chest surgery in the future. It does not constitute individual medical advice and we recommend that patients engage in comprehensive consultations with their healthcare teams to determine the best approach for their unique circumstances.

test