(Please note that we've¹ 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".
Per this post by 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:
all valid scientific studies over decades, which were excluded by the Cass Review because they weren't "double blinded controlled studies" (which is medically unethical);
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: 😞
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:
Get a prescription via a private online gender service from an EU medical professional.
Travel to Northern Ireland to pick up the prescription.
Travel back home to use it to support their trans kid.
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.
Temporary ban extension number 2 😞
On 6th November 2024, a 2nd extension to the temporary ban was created, which will come into force on 27th November 2024 and last until the end of 31st December 2024.
Fortunately, it was only a time extension: not an expansion of the meds being blocked.
Indefinite ban
We bleeping hate this country. On 11th December 2024, an indefinite ban was imposed by the scumbags in power, under the false guise of safety. This will come into force from 1st January 2025 :FaceExhaling:
And now for the good news 🥰
GnRH antagonists
Weasel isn't as smart as he thinks he is. Under Article 2, they've continued to define GnRH analogues as:
a medicinal product that consists of or contains buserelin, gonadorelin, goserelin, leuprorelin acetate, nafarelin or triptorelin
It's been this way since the original temporary ban was introduced by the previous government and nobody has updated the wording.
Whilst technically calling them analogues isn't incorrect, all of the medications listed above are actually more-specifically GnRH agonists.
Just like the original order, they've ignored GnRH antagonists, as these don't tend to be typically prescribed for trans+ GAHT, despite being just as safe and effective, with the same low-risk profile.
GnRH agonists and antagonists are both types of GnRH analogues. It's just that, for some reason, the agonists tend to be prescribed rather than the antagonists.
The wiki page on GnRH antagonists even specifically states in the Other uses section:
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 ("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:
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 feminising GAHT (aka feminising hormone therapy), 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.
Whilst puberty blockers are considered the gold standard:
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).
Other alternatives to these do exist and are commonly available.
Why no mention of 5-alpha-reductase inhibitors like finasteride or dutasteride? Because all they do is reduce the conversion of testosterone into dihydrotestosterone (DHT). 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 interact badly with micronised progesterone.
Spironolactone
Spironolactone 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.
The only safe progestogen for feminising GAHT is bioidentical micronised progesterone, and only after at least 6 months and having reached stage 3 on the Tanner Scale. It's best to avoid progestins at all costs, due to their inherent risks.
Bicalutamide
Now 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
Bicalutamide is a first-generation non-steroidal anti-androgen and 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. 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.
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, 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) 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.
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 😞
Of these, enzalutamide appears to be beginning to be used as part of feminising GAHT, at a dose of 160 mg daily, and the drug is approved by NICE at this dose.
Apalutamide has been approved by NICE at a dose of 240 mg daily.
Darolutamide, the newest of the meds, has been approved at a higher dose of 600 mg twice daily.
Each of these has its own risks and side effects that should be reviewed and taken into account. Enzalutamide purportedly "shows no risk of elevated liver enzymes or hepatotoxicity", but both it and apalutamide list a low possible risk of seizures.
Anti-oestrogens
There are anti-oestrogens, particularly SERMs, 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.
Monotherapy
It'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 hormones.
For people with testes taking feminising GAHT, sufficient estradiol indirectly puts testes into sleep mode.
For people with ovaries taking masculinising GAHT (aka masculinising hormone therapy), sufficient testosterone likewise puts ovaries into sleep mode.
For those taking testosterone, please do be careful not go above recommend peaks, as otherwise testosterone aromatisation will kick in and convert the excess into estradiol.
Aromatase is localized in the endoplasmic reticulum where it is regulated by tissue-specific promoters that are in turn controlled by hormones, cytokines, and other factors. It catalyzes the last steps of estrogen biosynthesis from androgens (specifically, it transforms androstenedione to estrone and testosterone to estradiol).
Please note that the figures quoted below are the typical figures for trans adults. Even WPATH SOC8 seems to have no defined ranges for trans youth, just same vague dosage suggestions adapted from the Endocrine Society Guidelines under "Appendix C GENDER-AFFIRMING HORMONAL TREATMENTS" within "Table 3".
Feminising GAHT
For feminising GAHT in adults, monotherapy typically requires maintaining an oestradiol trough of ~734 pmol/L (200 pg/mL). It varies from person to person, so some folks might need as little as ~367 pmol/L (100 pg/mL) or as high as ~918 pmol/L (250 pg/mL).
You'll know if their oestradiol trough is sufficient if their testosterone level is <=2.4 nmol/L, though <=3 nmol/L is often still considered to be within the high-end of normal range. Please note that the target range varies wildly, with ranges such as 30-100 ng/dL (~1.04 to ~3.47 nmol/L) and <50 ng/dL (~1.73 nmol/L).
Please note that there's a lot of scaremongering over oestradiol level. The NHS typically demands you be within 400 to 600 pmol/L... despite the fact that the NHS considers normal, safe ranges during menstruation to be:
Mid-luteal: 180 to 1068 pmol/L
Peri-ovulatory: 349 to 1590 pmol/L
Broadly-speaking, an oestradiol range that is considered safe in the long-term for monotherapy is 200 to 400 pg/mL (~734 to ~1469 pmol/L). If you wish to be more cautious, then you could aim for 200 to 300 pg/mL (~734 to ~1101 pmol/L).
Masculinising GAHT
For masculinising GAHT in adults, the targets vary and keep changing.
On the previous 2024 version of Tavistock and Portman guidance ("Treatment of Gender Dysphoria in Trans masculine People v12.4.1"), the levels were listed as follows when using the prescription testosterone medication Sustanon 250 mg/mL every 2-4 weeks:
a rather-low testosterone trough of ~10-12 nmol/L "on the day of the injection just before it is administered";
a peak of ~25-30 nmol/L "one week after the injection".
The aim of therapy is to achieve trough testosterone levels at the bottom
of the normal male range (8-12 nmol/l) on the day of the injection, just
before it is administered, and to achieve peak testosterone levels in the
high normal male range but less than 30 nmol/l one week after the
injection.
For context, international guidance is 300 to 1,000 ng/dL (~10.4 nmol/L to ~34.7 nmol/L).
The NHS trough aim allows for a narrow testosterone range that is right at the very low end of tolerability and actually goes below it. Please note that low testosterone levels are associated with low mood and low energy.
In relation to arbitrarily taking a blood test 1 week after administration, please note that Sustanon 250 tends to peak within a few days, then steadily falls. (Put something like "sustanon 250 level curve" into your preferred search engine and look for image graphs: you'll soon see what we mean.) It's just nonsense endocrinology!
For Nebido 1000 mg (4 mL), the testosterone trough range is 10 to 15 nmol/L, which is low, but not as ridiculously bad as the guidance for Sustanon 250.
With testosterone gel (testogel), the guidance is very odd. They aim for a target range of 15 to 20 nmol/L, which is fairly decent... but they want this to be tested 4 to 6 hours after application, rather than at trough... which kind of makes their guidance dumb AF.
To give you a real-world comparison, our testosterone level before starting feminising GAHT was ~18.6 nmol/L in our late 30s. Given that our voice had broken at age 10 and fully dropped by age 11, we are fairly sure our testosterone level was much higher than 18.6 nmol/L back then!
You'll typically know if your kid's testosterone trough is sufficient if their oestradiol level is under 150 pmol/L, though some folks may be up to around 180 pmol/L.
Benefits of monotherapy
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 GAHT, monotherapy is most easily achieved by a daily high-dose of oestradiol in the form of oestrogel (oestrogen gel) typically applied to the thighs or abdomen, but could in theory be achieved by sufficient patches applied twice weekly. Transdermal methods can benefit from being applied on the upper buttocks, but this will not be convenient or comfortable for everyone. Injections are sadly not available on prescription, and implants will be very, very expensive and only privately prescribed.
For masculinising GAHT, 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.
Blood tests
These can be done privately, completely avoiding the need for the NHS.
We've already written up a shorter post with links to other resources here.
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: :HeartHands:
Here is a non-exhaustive list of organisations who may be able to offer you some immediate support:
Edits: Apologies for all the typos. We're trying to gradually get rid of them all 😅 Further apologies for the minor formatting edits as we notice issues.
Edits 2025-08-19:
Added additional details for why we cyproterone acetate isn't recommended, including details from Wiki Trans (French resource).
Added a link to a later post we've made to other resources.
Updated some masculinising info based on most-recent NHS guidelines, mostly to show how dumb the guidance is.
Fixed at least one dead link.
Added in a note about switching terminology to GAHT.