Experts Call for Better Guidance on Puberty Blockers and Sexual Well-Being

A new expert recommendation published in Nature Reviews Urology addresses one of the most clinically sensitive and publicly debated questions in transgender healthcare: what happens to sexual development and sexual well-being when puberty is suppressed with gonadotropin-releasing hormone (GnRH) analogues in transgender and gender-diverse (TGD) adolescents. Despite the increasing clinical use of these medications worldwide, the authors emphasize that robust evidence on their effects on sexual development, sexual function and later sexual well-being remains strikingly limited. In response, an international, multidisciplinary team has synthesized the available literature with extensive clinical experience to produce practical recommendations for clinicians, adolescents and families, alongside a detailed agenda for future research.

The work was led by Isabelle S. van der Meulen and Sabine E. Hannema of Amsterdam University Medical Center, together with colleagues spanning endocrinology, urology, psychology, sexology and gynaecology. This breadth of expertise was deliberate. The authors argue that questions about puberty suppression and sexuality cannot be answered from within a single discipline, because puberty itself is a phenomenon that unfolds simultaneously across the endocrine system, the developing brain, the genital organs and the psychosocial life of an adolescent. The recommendations were further shaped by input from a round table session held at the 2025 conference of the European Professional Association for Transgender Health (EPATH), which brought together clinical and community perspectives on how these conversations should be handled in practice.

At the physiological level, GnRH analogues work by suppressing the hypothalamus–pituitary–gonadal axis, the hormonal cascade that normally drives the physical transformations of puberty. By halting the release of gonadotropins, the medications pause the production of sex steroids and thereby interrupt the development of secondary sexual characteristics such as breast growth, voice deepening, genital development and changes in body composition and distribution. The rationale is to give adolescents with persistent gender incongruence time to explore their identity without the distress of unwanted, and in many cases irreversible, pubertal changes. When treatment is stopped, endogenous puberty resumes; when followed by gender-affirming hormone treatment, a puberty aligned with the adolescent’s gender identity is induced instead.

However, the same sex steroid hormones that drive physical pubertal changes also play roles in genital maturation, neural development and possibly in sexual response and pleasure. Androgens, for example, contribute to clitorophallus growth and penile tissue remodeling, while estrogens influence vaginal and vulvar development. Suppression of these hormones during a critical developmental window therefore raises legitimate biological questions about whether later genital sensitivity, sexual function or capacity for pleasure might be affected. The authors stress that the existing evidence base is too sparse to answer these questions definitively, and that this uncertainty is precisely why structured, evidence- and experience-based counselling is so important for adolescents and their families who are weighing these decisions.

The recommendations generated by the expert group centre on providing developmentally appropriate information about puberty, puberty suppression and sexual development. Clinicians are encouraged to explain, in language suited to the adolescent’s age and cognitive stage, how the hypothalamus–pituitary–gonadal axis works, what GnRH analogues do to it, and what is known and unknown about the consequences for sexual maturation. Importantly, the experts also highlight psychosocial dimensions of sexual development, including the effects of stigma and minority stress, which research in sexual minority populations has shown to be strongly linked to psychological well-being and, by extension, to sexual well-being. Counselling that ignores these social realities, the authors suggest, would present an incomplete picture of what shapes a young person’s sexual development.

Another core recommendation concerns individualized decision making around fertility and future surgical options. Puberty suppression at early pubertal stages limits the development of gametes, complicating options for fertility preservation, and it also affects the tissues available for later gender-affirming genital surgery, such as vaginoplasty. Decisions about when to start suppression, whether to pause treatment to allow sperm or oocyte maturation, and how to counsel about surgical implications must therefore be tailored to each adolescent’s circumstances, values and goals. The experts emphasize shared decision making, in which adolescents, families and clinicians weigh benefits, risks and uncertainties together, supported by decision aids and ethics support tools that have been developed and evaluated in recent years within transgender care.

Equally central is the promotion of positive, open communication about sexuality itself. The authors note that sexuality remains a taboo topic in many clinical settings, including youth mental health care, and that transgender adolescents frequently report wanting their healthcare providers to talk with them about sexuality and gender diversity rather than avoiding the subject. The recommendations call for clinicians to proactively address sexual desire, arousal, pleasure, relationships and masturbation as normal components of adolescent development, rather than treating sexuality purely as a domain of risk or dysfunction. Tools designed to open these conversations with young people, including question-based conversational aids developed for gender-diverse youth, are highlighted as practical resources that can help clinicians overcome their own hesitation and make these discussions routine rather than exceptional.

On the research side, the article identifies major knowledge gaps and sets out priorities for filling them. Longitudinal studies following TGD individuals from the start of puberty suppression well into adulthood are needed, ideally combining quantitative measures with qualitative approaches that capture lived experience. The first exploratory studies in this area have offered a measure of reassurance: they found similar sexual well-being in young adults who received puberty suppression during adolescence and those who received gender-affirming hormone treatment without prior suppression. Research on sexual functioning after vaginoplasty, and on the influence of puberty suppression timing on later sexual function, has begun to map this terrain, but the authors caution that these are early, often small studies that cannot yet support firm causal conclusions. Research frameworks adapted from other fields, such as the target trial framework for observational data, may help strengthen causal inference in this challenging population.

A further priority is the development of TGD-specific instruments to assess sexual development, sexual function and sexual satisfaction. The authors argue that existing sexual health measures, which were largely designed for cisgender populations, fail to capture the diversity and intersectionality of sexual experiences among TGD individuals, including the interplay of gender dysphoria and gender euphoria with desire, pleasure and body satisfaction. Without valid, sensitive measurement tools, the field cannot accurately track outcomes or evaluate whether and how puberty suppression affects sexual well-being over the life course. Genital sensitivity itself, including erogenous sensation in surgically constructed and hormone-influenced genital tissue, is named as an area requiring both psychophysical and patient-reported investigation.

Ultimately, the expert recommendation is framed not as a verdict on puberty suppression but as a framework for honest, compassionate and scientifically grounded care. By integrating evidence where it exists, transparently acknowledging uncertainty where it does not, and centering the voices and experiences of TGD adolescents themselves, the authors aim to support individuals considering puberty suppression, their families and their clinicians in optimizing both care and long-term well-being. The call for longitudinal, interdisciplinary research signals that the scientific conversation is far from over, and that the coming decade of work will be critical in transforming clinical experience into rigorous evidence about how best to support the sexual development and sexual well-being of transgender and gender-diverse young people.

The biological rationale for caution rests on well-established endocrine principles. Sex steroids act not only as activators of sexual response but also as organizers of tissue development during defined windows of maturation, a concept long recognized in classical studies of pubertal staging in boys and girls. Analogies can also be drawn from conditions such as congenital hypogonadotropic hypogonadism, in which individuals experience absent or delayed endogenous puberty and require hormonal induction; research in these populations has examined psychosexual development under long-term treatment and offers a useful comparative lens for understanding how pubertal hormone exposure relates to later sexual function.

The clinical context for these recommendations has been shaped by several prior expert documents. The European Society for Sexual Medicine has issued position statements addressing hormonal management and sexual function in adolescent and adult trans people, as well as sexual well-being after gender-affirming surgery, and a working group of the European Society for Paediatric Endocrinology has published expert opinion on the endocrine management of transgender and gender-diverse adolescents. The new recommendation complements these efforts by focusing specifically on the intersection of puberty suppression and sexuality, an area those documents addressed only briefly.

Conceptual framing also matters. The World Health Organization defines sexuality broadly, encompassing sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction, and the ICD-11 now classifies gender incongruence outside mental and behavioural disorders. Within this framing, sexual well-being is understood as a positive dimension of health rather than merely the absence of dysfunction, which reinforces the authors’ argument that counselling should address pleasure and satisfaction, not only risk.

The evidence base itself has grown out of decades of longitudinal cohort research, most notably the Amsterdam Cohort of Gender Dysphoria, which has documented diagnostic and treatment trajectories since the earliest days of the Dutch protocol. Recent pilot studies from this tradition have begun comparing sexual function in adults treated with gender-affirming hormones with or without prior pubertal suppression, and examining sexual satisfaction following vaginoplasty in relation to the timing of suppression. Although preliminary, these studies represent the first direct empirical tests of questions that were previously addressed only through theory, and they provide the methodological foundation on which the recommended larger, longitudinal and mixed-methods research programme can now be built.

Subject of Research: The effects of puberty suppression with GnRH analogues on sexual development and sexual well-being in transgender and gender-diverse adolescents

Article Title: Puberty suppression and sexual well-being in transgender and gender-diverse individuals: evidence- and experience-based counselling and future research directions

Article References: van der Meulen, I. S., van den Boogaard, E., Özer, M., Bungener, S. L., Vrouenraets, L. J., & Hannema, S. E. (2026). Puberty suppression and sexual well-being in transgender and gender-diverse individuals: evidence- and experience-based counselling and future research directions. Nature Reviews Urology. https://doi.org/10.1038/s41585-026-01182-3

Image Credits: AI Generated

DOI: 10.1038/s41585-026-01182-3

Keywords: puberty suppression, GnRH analogues, transgender health, gender-diverse adolescents, sexual well-being, sexual development, fertility preservation, shared decision making, gender-affirming care, EPATH, Nature Reviews Urology, expert recommendation