The Ethics of Hormone Therapy

To Affirm or Not To Affirm: The Ethical Implications of Hormone Therapy for Transgender Youth

By Sophia Gandhi

Access to hormone therapy for transgender youth is one of the most debated political, medical and bioethical topics of our world. As the number of transgender adolescents rises, and more and more seek out this type of care, many doctors, parents and politicians are conflicted over whether or not it is the right decision to provide it, given both the novelty of the treatment, and the age of the primary population. Throughout this paper, all sides of this debate will be discussed, taking into account various perspectives, stakeholders, values and frameworks.

Table of Contents

• Abstract
• Stakeholders
• Background Information on Puberty Blockers
• Background Information on Hormone Replacement Therapy
• History of Gender-Affirming Medical Care
• Mental Health
• Frameworks
  • Consequentialism
  • Virtue Ethics
• Informed Consent
• Parental Autonomy
• Role of Doctors
  • Responsibility of the Medical Professional
  • Professional Autonomy
• Role of the Government
• Principle of Justice
• Conclusion
  • Closing Statement

Nearly seconds after a newborn baby emerges from the womb, an exhausted yet relieved doctor declares three life-changing words, based solely on the external genitalia of the child. Either, “It’s a girl!” or “It’s a boy!”, declared with such enthusiasm, that it would almost be a disappointment if it were to be proved wrong.

However, as many will argue, there is a distinct difference between biological sex and gender, as one is identified solely by factors including genitalia, hormones and chromosomes, while the latter is a more flexible definition, based on one’s perception of themselves. Although often aligning, as someone may be assigned female at birth and continue to identify as a woman for the rest of their life, there are cases where one does not feel their biological sex assigned at birth aligns with their gender. As a result of these misaligning feelings, an individual may develop gender dysphoria, a condition commonly associated with transgender identity. Gender dysphoria is characterized as the distress or discomfort an individual feels when their gender identity does not align with their sex assigned at birth. While this feeling may fade over time in some individuals, it may persist for others, leading them to identify as transgender. Varying from person to person, some transgender individuals will seek medical interventions to affirm their gender identity, while others are content with their body as it is. 

Access to gender-affirming medical care (GAMC) for transgender youth is one of the most debated political, medical and bioethical topics of our country. My key ethical interest in this research project lies in trying to make a judgment as to the age at which a child or adolescent ought to be allowed to undergo medical transition, or alter their body through either puberty blockers or hormone therapy to affirm their gender identity. 

This paper will discuss the applications of hormone therapy for transgender youth, specifically puberty blockers and hormone-replacement therapies (HRT) for individuals under 18, and dissect their effects on both physical and mental health. I will analyze historical views of transgender healthcare compared to the modern perspective we now have, as well as the variety of attitudes towards this treatment from various medical professionals, parents and transgender adults. To conclude, I will provide my own analysis of the most pressing ethical considerations, and propose ideas to guide physicians, parents and adolescents when considering the decision making ability of a minor. Ultimately, I assert that the life experiences, capacity to understand and general knowledge in an individual range greatly between the ages where hormone therapy is often considered for transgender youth, making it nearly impossible to determine and apply universal standards of care for this population. 

Although the term gender-affirming medical care refers to any medical care pertaining to transgender individuals, I will not be discussing any treatments other than hormone therapies in this paper, including surgeries. GAMC for transgender youth has become an increasingly discussed topic in recent years. Its popularity is often attributed to rising numbers of transgender individuals, specifically young people, in the past decade. In 2017, the Williams Institute used statistical modeling to predict a transgender youth population of approximately 0.7%, but a high school survey in 2022 showed the number was closer to 1.4% (Ghorayshi). Researchers believe overall acceptance and education about transgender identity has grown, which has allowed transgender individuals to come out without as much fear of discrimination and disrespect. Social contagion is another factor that may explain the increase in transgender adolescents, as social media is becoming more of a platform for people to share their personal experiences. More information about GAMC in online spaces makes it more accessible for youth to learn more, as youth presence online is fairly high. More numbers of transgender youth means more individuals who desire access to gender affirming medical care, sparking a rise in demand for a highly controversial medicine. For most of history, being transgender has been viewed as a mental illness, rather than a piece of someone’s identity. Many medical professionals still believe that transgender individuals, specifically youth, are not actually transgender, but rather in need of mental health interventions and therapy to affirm them with their sex assigned at birth. These beliefs continue to inform treatment for transgender people today, oftentimes causing disagreements over the best practices for transgender youth.

To clarify, while the transgender youth population in the U.S. is estimated to be around 1.4%, only 11% of this population desires access to GAMC (Trevor Project). Many transgender youth follow a process of social transition instead, allowing them to outwardly present as the gender they identify as without any medical interventions. This may include expressing oneself through different clothing, make-up or hair, or using a different name or pronouns at school or in other public spaces. Oftentimes, transgender adolescents seeking GAMC have already undergone this process, some since an age as young as 3 or 4, and some more recently. Aspects of social transition may present themselves in younger children, including the toys they prefer to play with and the clothes they feel comfortable leaving the house in, which may prompt a parent or medical professional to question a child’s gender identity. Traits like clothing and hair choices are sometimes viewed as signs of a child who may identify as transgender, but this is not necessarily true for all children. Some medical professionals may also require a specific length of social transition, for individuals of any age, to solidify one’s gender identity before beginning to provide GAMC. 

Regardless of how long an individual has identified as transgender, treatment approaches are often viewed through a very black and white lens. Given the question of which to prioritize for a transgender patient, mental or physical health, two polarized arguments can be outlined. By providing treatment, doctors expose children to a plethora of risks given the novelty of this treatment, and the unknowns about its effects to one’s body and brain during puberty. Without medical treatment, the risk of severe mental illness, including depression, anxiety and suicidal ideation, increases. Having taken an oath to do no harm, doctors have obligations to keep the best interests of the patient at the forefront while simultaneously minimizing harm. By withholding this care and preventing physical harm as a result of puberty blockers, the mental suffering a patient feels can have detrimental consequences, including suicide. 

Just because a practice increases an individuals well-being, does that mean it should be considered a medical standard? Take the example of an intellectually disabled female, who is of menstruating age. As the 1927 U.S. Supreme Court case Buck v Bell ruled, a compulsory sterilization was permitted with the argument of benefits to personal hygiene, emotional outbursts and seizure activity in intellectually disabled and epileptic individuals. However, using the argument that a practice which increases one’s well-being should be considered a medical standard, this ruling would be considered unethical, because it normalizes forced sterilization as a medical standard. Similarly, this idea can be applied to puberty blockers. Although there is evidence that they support the well-being of individuals with gender dysphoria, should it be considered a medical standard of care, considering the unknowns and possible physical harms? (Kulsea)

Throughout this paper, I will expand on each of these questions, explore the gray areas in between the two sides, and analyze the ethics of this treatment from two frameworks, Consequentialism and Virtue Ethics. The Principle of Nonmaleficence, Justice and the values of Safety and Responsibility will also be examined with respect to parents, medical professionals, and legislators. Lastly, I will dive deeper into the role of the parent, the role of the doctor and the influence they have over a patient’s decision making. This analysis will serve as building blocks to reach a final answer to my main ethical question; At what age should transgender youth be allowed to undergo medical transition, including puberty blockers and hormone therapy?

There are multiple levels of stakeholders impacted by this treatment. Primary stakeholders include transgender youth and their parents and legal guardians, as well as the medical professionals providing this care. Secondary stakeholders include legislators and politicians, the FDA, the pharmaceutical industry, and society. The use of puberty blockers to treat transgender youth is an off-label use, because they have only been FDA approved to treat individuals diagnosed with Central Precocious Puberty (CPP). CPP is a rare condition that causes puberty to begin much earlier than the average age of 8 for girls and 9 for boys. While it is not uncommon for doctors to prescribe off label usages for various drugs, it can still be a risky process, especially for children. Also, because drug manufacturers cannot account for how much of their product is going towards an off-label use, drug shortages can occur as a consequence.

In August of 2022, there was a shortage of Lupron Depot Ped, a common puberty blocking drug approved for children with CPP. While there is no evidence that this occurred due to demand from transgender youth, a possible assumption can be made (FDA). The concern of the pharmaceutical industry is particularly important, due to the off-label use of puberty blockers. Manufacturers can still be held accountable for negative consequences as a result of the drug, even if they cannot control the off-label use. Society is also a major stakeholder, as a decision regarding youth autonomy in the area of GAMC would have implications in other areas of youth medical care and consent. Most importantly, for a minor to be able to consent to a medical procedure of any sort, they have to be able to understand the possible consequences associated with it.

One of the most common gender-affirming medical treatments for adolescents with persistent gender dysphoria is puberty blockers. Gonadotropin releasing hormone (GnRH) agonists, informally referred to as puberty blockers, are puberty blocking drugs, created and FDA approved in 1993 for children diagnosed with Central Precocious Puberty (CPP), a condition which causes puberty to begin earlier than ages 8-9 (Mayo Clinic). The most commonly used puberty blocking drugs include Histrelin, Leuprolide, Goserelin, and Triptorelin. They can be dosed either of two ways; through the arm with injections every three months, or through implants which need to be replaced every 12 months. These medications work by suppressing endogenous sex hormones, the natural hormones released during puberty within one’s body. GnRH is a hormone usually synthesized and released by the hypothalamus, which has control over the pituitary gland. The pituitary gland is in charge of regulating growth and all other glands. GnRH agonists imitate these hormones, initially producing a surge in endogenous sex hormones, which overstimulates GnRH receptors, ultimately stopping the pituitary gland from responding to GnRH and causing a decrease in endogenous sex hormones (Pan and McKay). In individuals assigned female at birth, this means releases of estrogen are blocked, preventing breasts from developing, and stopping or partially stopping menstrual cycles (St. Louis Children’s Hospital). In individuals assigned male at birth, the release of testosterone is suppressed, preventing development of facial hair and a deepening voice (Healthline). Most doctors recommend staying on puberty blockers for about 2 years, but not much research has been conducted on the long term usage of puberty blockers. 

Parents and children inquiring about puberty blockers usually begin with bringing it up to their primary care physician, who then refers them to a pediatric endocrinologist, a doctor who can evaluate a child’s current hormone levels, and take proper measures to ensure hormones stay regulated while receiving treatment. Due to both its novelty, and disagreements within the medical community, there are no universally enforced guidelines for providing puberty blockers to adolescents. While some doctors may require a referral for care after multiple visits with a psychologist, others may be hesitant to provide care at all. A 2016 survey of endocrinologists found that 80% received no formal training on caring for transgender youth (Endocrine Society). This lack of education may affect patient care and patient outcomes, which is why many families may opt to visit gender clinics instead. Gender clinics have become more abundant in the past few decades in some universities and hospitals, as well as centers like Planned Parenthood, as they often have more comprehensive training and transparency relating to GAMC (Lanzillo). 

Most medical professionals agree that puberty blockers are not considered a permanent treatment, and at any point they can be stopped and the endogenous puberty will continue anywhere from 6-18 months later. This allows individuals who desist, or cease to identify as transgender, to undergo their endogenous puberty and stay on track with peers, and leaves the door open for possible fertility preservation methods, as sperm and eggs will continue to be produced once puberty blockers are stopped. Puberty blockers allow adolescents questioning their gender identity a pause, and a chance to decide whether or not they want to go through with endogenous puberty. It also provides a short period of time for mental health concerns related to gender dysphoria to be considered. 

The recommended course for transgender youth is to begin puberty blockers around ages 10-13, around the onset of puberty and the first signs of secondary sex characteristics (Steensma et al). According to a study by Steensma and colleagues about childhood gender dysphoria from Amsterdam, adolescents who had experienced gender dysphoria cited the ages of 10-13 as crucial to their identity. Many felt that around those ages their gender dysphoria either heightened or subsided, making it a critical time for decisions about medical interventions. Starting puberty blockers as young as 10 or 11 years old often causes concern for many individuals, especially parents. While doctors do caution against staying on puberty blockers for longer than approximately two years, the Endocrine Society suggests starting hormone replacement therapy (HRT) at age 16. Hormone replacement therapy is the process of administering either estrogen or testosterone to permanently alter an individual’s physical characteristics. However, more and more individuals are beginning to receive estrogen and testosterone at ages 13 and 14, as they have started puberty blockers younger due to puberty beginning earlier in their bodies. A major consideration for parents, doctors and children alike is the possible effect puberty blockers may have on fertility. While puberty blockers themselves may not have an effect on one’s fertility, future pursuing of HRT is believed to. In all individuals, beginning GnRH, a puberty blocker, causes them to enter a hypogonadotropic state, meaning they will produce little to no sex hormones. In transgender boys, the absence of estrogen affects menstrual cycles (Delemarre-van de Waal and Cohen-Kettenis). However, fertility and hormone therapy is not an exact science, as is evident by a 2020 research study from Boston IVF, where a transgender man who began receiving testosterone at age 18 underwent IVF at age 21, and had a seemingly identical egg yield to that of cisgender woman (Boston IVF). The misconception that infertility is caused solely by puberty blockers stems from the fact that an immediate procession from blockers to HRT prevents an individual from being able to reproduce. This occurs due to one’s body never going through endogenous puberty, which doesn’t allow for their gametes to mature for possible fertility preservation options. 

By starting puberty blockers younger, around ages as young as 10 or 11, the transition to HRT occurs earlier than 16 in most cases, causing decisions about fertility preservation to happen much earlier. Because of this, a possible concern is that a 13-14 year old child may not fully understand the extent of their decision regarding fertility, and their future ability to have biological children. In a 2017 study of 103 transgender youth, only 13 had formal consultations discussing fertility preservation before beginning hormones. Of the 13, only five opted to undergo either sperm or oocyte cryopreservation, which is the process of harvesting and freezing sperm or eggs for future use (Chen et al.). Part of the reason why the other seven opted out of fertility preservation may have been due to the fact that to preserve gametes, an individual needs to go through endogenous puberty, or else the proper structures will not mature, and sperm and eggs cannot be harvested. This requirement may discourage many from preserving gametes, as they prioritize hormones over future fertility. For transgender women, sperm cryopreservation is the most commonly used method to preserve fertility, but it must be done before an individual is exposed to estrogen. Prolonged exposure to estrogen can damage testicular tissue, affecting the production of sperm. While there have been several cases of uterine transplantation, or the transplanting of a uterus into a patient’s pelvis, which would potentially allow an individual to carry a baby, this treatment is very much still in its infancy, and is not currently a viable option for transgender women (Ferri). Although transgender men can also undergo oocyte cryopreservation, they may also be able to conceive a child upon discontinuation of testosterone (Amato). Another option is ovarian tissue cryopreservation, which is the process of harvesting and freezing one ovary to later be placed back into the body, and help an individual get pregnant. Although often used for cancer patients undergoing chemotherapy, some transgender men will undergo the process as well, but it also requires the discontinuation of testosterone, as the hormone is considered a teratogen, and can cause possible deformities for a fetus (Memorial Sloan Kettering Cancer Center).

A larger concern raised from this fertility preservation study was how doctors are approaching or informing their patients about the consequences of beginning hormone therapy, as not every family is educated enough about these topics to make fully informed decisions, and some may not even be aware that fertility preservation is something that needs to be considered. As Laidlaw, M.D. and colleagues discuss, infertility is also a serious health condition, which can lead to possible negative mental health outcomes. Individuals assigned female at birth who are naturally infertile often experience depression at twice the rate of the average population (Laidlaw et al.).Utilizing puberty blockers for transgender youth is an off label use of the drug. Currently, in the US, there is no FDA approved drug to treat gender dysphoria in transgender youth. In recent years, the use of off-label medications has grown, as more medications are discovered to treat symptoms other than their intended usage. Most common amongst pediatric patients is the use of antihistamines, drugs to treat allergies, to treat upper respiratory tract infections and antidepressants to treat attention deficit hyperactivity disorder (ADHD) (Taylor).

Like many drugs, off label or not, there are safety concerns and side effects associated with taking the medication. One is the warning GnRH carries for a condition called pseudotumor cerebri, where an excess of cerebrospinal fluid is produced, which puts pressure on the skull. After six reported cases of the condition, the FDA added it as a warning associated with the medication, but further cases have yet to be reported (FDA). Most concerning for many is the effects puberty blockers can have on bone development, as the primary consumers are children during a period of rapid and important growth. During endogenous puberty, bone mass in adolescents increases, but on blockers this increase does not occur. While for many individuals the problem is resolved when they either go on to receive gender affirming hormones, or resume endogenous puberty, a small percentage has shown alarmingly low rates of bone strength compared to cisgender peers.

In a 2006 study of transgender adolescents receiving GnRH, a “significant decrease” of bone density appeared during treatment.

Society for Evidence Based Gender Medicine

It was concluded that more long term research was necessary in order to determine if this was a serious risk. These results were supported by a British study in 2019, where after two years of GnRH, bone mass density scores decreased among patients (Joseph et al.). Not only does this have ethical implications for younger children seeking to start puberty blockers, but also for those who are currently receiving them or have been on blockers in the past. New research and developments in treatment may require these specific individuals to seek extra medical care or interventions due to problems from puberty blockers. Many parents and doctors also hesitate to prescribe medications for transgender youth, citing the fact that some children do not continue to identify as transgender as they grow up. These individuals are known either as detransitioners or desisters. Desisters are individuals who experience childhood gender dysphoria, but “desist”, or stop experiencing this dysphoria around the onset of puberty, before any medical interventions. Clinical psychologist Dr. James Cantor prepared an expert report in 2022, when he was hired as an expert witness to defend Texas Governor Greg Abbott’s directive to investigate the parents of minors who were receiving GAMC in the state. His report included information about 11 cohort studies with pre-pubertal children with gender dysphoria. Of the 11 studies, which spanned multiple countries, various methods of data collection, and four decades, between 66-81% of children’s desires to be the opposite gender ceased (Cantor). Many parents and doctors alike worry this percentage is similar amongst individuals who decide to begin medical transition but later revert back to their gender assigned at birth, often referred to as detransitioners. However, from available research, the percentage of detransitioners is thought to be only a small fraction of individuals. In a 2022 study from Olson and colleagues, a group of transgender youth were examined after an average of 5 years since they began socially or medically transitioning. Two and a half percent of the population reported detransitioning to their gender assigned at birth, but the reasons why are not listed (Olson et al.). While there is not one prevalent reason, individuals may detransition due to environmental or internal factors. In a 2021 survey by Lisa Littman, 100 detransitioners who had undergone medical and/or surgical procedures responded. Their reasons for detransitioning included:

“experiencing discrimination (23.0%); becoming more comfortable identifying as their natal sex (60.0%); having concerns about potential medical complications from transitioning (49.0%); and coming to the view that their gender dysphoria was caused by something specific such as trauma, abuse, or a mental health condition (38.0%). Homophobia or difficulty accepting themselves as lesbian, gay, or bisexual was expressed by 23.0% as a reason for transition and subsequent detransition. The majority (55.0%) felt that they did not receive an adequate evaluation from a doctor or mental health professional before starting transition”

Lisa Littman

Delaying puberty for a year or two with the use of puberty blockers may have given some individuals more of a chance to better understand their gender identity before choosing to continue medical transition. In a survey of transgender adults, ages 18-36, 16.9% of respondents wished they had received puberty blockers when they were younger. Out of the respondents, only 2.5% did receive this treatment (Turban et al.).

After taking puberty blockers, some individuals may choose to begin hormone replacement therapy, which includes either feminizing or masculinizing hormone replacement therapy (HRT). Feminizing HRT includes estrogen and progestin, while masculinizing HRT includes testosterone. Progestin is a synthetic chemical that mimics the effects of progesterone (Healthline). Individuals who may not have had access to puberty blockers may also seek HRT, at any age. The biggest difference between puberty blockers and hormone therapy is that effects of puberty blockers are believed to be fully reversible, with extremely rare lasting consequences, while hormone therapies can have irreversible, lasting physical changes on an individual’s body. As mentioned earlier, these may include changes in hair growth, skin texture, and physical secondary sex characteristics. 

In an individual assigned female at birth, the dominant hormones present include estrogen and progesterone. Progesterone supports menstrual health, and helps to maintain pregnancy during early stages. It does this by preparing the uterine lining, which is shed when the egg is not fertilized, causing a period. If conception does occur, progesterone creates a safe environment for the egg inside the uterus. Progesterone levels spike during menstruation, and decrease during ovulation (Cleveland Clinic). Estrogen is also produced in individuals assigned female at birth. It serves a multitude of purposes, and is mainly produced in the ovaries. Estrogen plays a role in growth and development, including one’s menstrual cycle, bone growth and optimal mood regulation (Healthline). In individuals assigned male at birth, the main hormone is testosterone. Testosterone affects sperm production, bone mass and growth, fat storage, and red blood cell production (Healthline).

Previous to beginning feminizing or masculinizing HRT, health care providers assess physical health, including personal and family history reviews, lab tests, and screening for certain conditions. A thorough discussion about birth control, sexual health and fertility is also considered a standard of care. Mental health evaluations may assess gender identity and dysphoria, existing mental health concerns, support systems and follow-up care, and goals for treatment. For transgender youth, all of these assessments include the involvement of a parent or guardian, as well as a pediatric endocrinologist and pediatrician. 

For transgender boys, HRT usually begins with the administration of a low dose of testosterone, regardless of prior puberty blocker usage. If an individual has undergone endogenous puberty, and been exposed to estrogen, testosterone may be able to shrink breast tissue, but it does not have an effect on height after one’s bones have finished maturing. Physical effects of testosterone may begin to occur as soon as 2-3 months into treatment, but the full effects often take years to develop. The full effect of an increase in muscle mass can take 2-5 years, deepening of the voice can take 1-2 years and may also require other therapies, facial and body hair growth can take 3-5 years, and clitorial growth can take 1-2 years. The dose of testosterone one receives slowly increases, until it reaches the normal male physiology range, which is 300-1000 ng/dl (Gardner and Safer). Dosages vary by how often an individual takes the hormone, and what type of application is used. Testosterone is considered a lifelong treatment to maintain physical characteristics, however some individuals may be satisfied with their appearance after a number of years receiving hormones, or need to stop treatment due to health concerns. 

For transgender girls, how HRT begins depends on previous care. If an individual has received GnRH previously, they can transition straight to estrogen as long as testosterone levels have decreased to the normal female range, which is 30-100 ng/dl. For individuals who have not received puberty blockers, their treatment begins with spironolactone, a medication classified as an androgen receptor, which blocks male sex hormone receptors. Once testosterone levels drop to the normal range, usually after 4-8 weeks, estrogen can be administered along with spironolactone. Administration of estrogen also continues to lower the amount of testosterone the body produces, allowing estrogen to physically affect one’s body. Similarly to testosterone, some changes may begin as soon as 1-3 months, but the full effects can take years to develop. Fewer erections, decreased libido and slowed scalp hair loss all can take full effect within 6 months – 2 years. Testicular atrophy, or decrease in testicle size and breast development can take 2-3 years, but breasts usually do not develop past a B size cup. Other physical effects include a decrease in muscle mass, and an increase in body fat, and less facial and body hair growth (Mayo Clinic). 

Like most medical treatments, there are risks associated with masculinizing and feminizing HRT. The physical risks are more thoroughly researched compared to GnRH because the applications of these hormones apply to more individuals. Estrogen is often used to manage menopause symptoms, including reducing the risk of osteoporosis, a condition that results from hormone changes, which causes bones to become more fragile, oftentimes during menopause. Due to this common use, more research has been done to explore the possible harm associated with estrogen. Individuals who have hormone-sensitive cancers, including prostate cancer, are often discouraged from taking estrogen, as it can have adverse effects on the cancer. Also, if an individual has problems with blood clots, a medical professional may advise against feminizing HRT. In a 2018 cohort study from Getahun and colleagues, researchers concluded that transgender women receiving feminizing HRT had a higher incidence of venous thromboembolism (VTE), or blood clots deep in a vein (Getahun et al.). However, this study may not be accurate, as researchers only had access to patient records, and could not account for other medications and conditions. Other physical risks include high triglycerides, high potassium and weight gain (Mayo Clinic). Physical risks associated with masculinizing HRT include weight gain, acne, male-patterned baldness, sleep apnea, mood swings and high blood pressure. Research on whether testosterone increases the risk of hormone cancers is still unclear (Mayo Clinic). In order to create a more reliable and valid study, there would need to be both an experimental group, who receives hormone therapy, as well as a placebo group, who would receive placebo hormones. However, giving a transgender patient placebo hormones without their knowledge raises ethical concerns, given the possible mental health consequences one could experience. In the past, most studies exploring cardiovascular health in individuals taking estrogen have been done on menopausal women, then applied to transgender women, but this also is not always reliable information that can be applied to both populations (Scher).

During the 1960’s, Dr. John Money became well known as the first doctor to pull off a successful sex change operation, where he inverted a penis and constructed a vagina, known as a vaginoplasty. His work at John Hopkins became widely known, which begged more interested patients. One of which was Frank and Linda Thiessen, parents of a set of identical twin boys, named Bruce and Brian. As babies, Bruce and Brian both required surgical procedures when Linda noticed they were having trouble urinating. Although his brother was fine, Bruce had his penis burnt off when the doctor botched his circumcision. Linda and Frank worried about Bruce’s future in terms of marriage, acceptance and inability for sexual functions, but were intrigued by Dr. Money’s claims that babies were born neutral, and their gender was merely a product of their environment. Through Dr. Money’s research on intersexuality, a condition where babies are born with ambiguities in external sex organs and internal reproductive systems, he came to the conclusion that when a baby was surgically operated on to craft either a penis or vagina, and then raised as the associated gender, 95% of the time, the patient continued to identify as such. From these experiments he concluded that rather than having a biologically instilled basis, gender was malleable in babies and young infants. Bruce’s case was taken on by Dr. Money, and in 1967 the baby underwent a full vaginoplasty. Dr. Money made it clear to Linda and Frank that the baby had to be raised as a girl with absolute certainty, and it was never something to be discussed or questioned, or else it could influence the gender of the baby. 

However, as the baby, called Brenda at this point, grew up, it was clear she leaned more towards traditionally masculine behaviors and activities. She resisted wearing dresses and showed no interest in feminine activities and toys. Her brother and peers viewed her as a tomboy at this point in time. Because of her peculiar rejection of traditional female gender norms, Brenda experienced bullying from classmates and intense psychological counseling from Dr. Money himself, in an attempt to align Brenda with his vision for her. As she started middle school, a visit to a clinical psychologist further conveyed Brenda’s discontent with her genitals, and suicidal ideation. When Dr. Money started to introduce estrogen to ensure her body developed like that of a biological female, Brenda was still strongly in disagreement. She dreaded taking the pills and developing a more feminine figure, and simultaneously, her suicidal ideation grew. Finally, at the age of 14, Brenda’s endocrinologist finally confronted her with the question of if she really wanted to be a girl when she was refusing a breast exam. Brenda clearly stated that she did not, causing her endocrinologist to go back on his recommendation for future genital surgery and continuation of hormones. Frank came clean to Brenda with the truth about her childhood, and Brenda immediately began the transition back to a man, and used the name David instead. Although David was able to rid his appearance of most of the feminine features that had developed, his mental illness stuck with him. After his school found out the truth about his “accident”, David attempted suicide for the first time, then again a week later. He worried about not being able to marry like his brother, and provide children for his future family.

“His brother, [Brian], had by that time married and become a father – everything that [David] had wanted for himself since high school. “I got so terribly lonely,” [David] says.”

John Colapinto

Eventually, David met a single mother of three children, who he later married. In 2004, he ultimately died of suicide at age 38 (New York Times).

This case study changed many views on the ongoing nature vs. nurture debate, a conversation debating whether one’s environment or inborn traits have a larger effect on their development. Specifically, it provided evidence for a biological basis of gender, stemming from a very young age. Not only does this apply to intersex children, who may be assigned one gender based on their external genitalia, but later identify with another, but it also applies to transgender individual, who like all children, are assigned a gender at birth based on their biological sex, but then show symptoms as they grown up and later feel that they identify as the opposite gender. It also provides evidence to support the fact that living and being perceived as the wrong gender can have detrimental mental health effects on the life and well-being of an individual. David started showing signs of suicidal ideation as young as eight years old, and throughout almost all of his childhood, he strongly believed he was not a girl. His discomfort with his body, opposition to female puberty, and the treatment he received from others when he did not conform are all experiences that many within the transgender population can empathize with. Like many individuals in history, David was treated through psychological means that denied his gender identity, rather than affirming it. 

Although the first record of gender-affirming surgery dates back to 1910, medical treatment besides psychoanalysis was not considered for transgender individuals until the 1950’s and 1960’s. This treatment aimed to alter one’s thinking and ultimately curb any desire to live as the opposite sex. In our world today, this would be considered a form of conversion therapy, a practice attempting to change one’s identity through various means, and one that has been continually criticized by activists, researchers and experts. Researchers in this field focused on early interventions to halt cross-gender behaviors, but despite more negative than positive results, they pressed on. Robert Stoller (1924-1991) and Richard Green (1936-2019), believed that feminine behaviors in youth assigned male at birth were a direct result of overly close relationships with their mothers. Their ideology was adopted by many, and they encouraged parents of the same gender to engage more with the child, and opposite-gender parents to engage less. However, this treatment tended to result in depression and feelings of betrayal from parents, to such an extent that the province of Ontario subsequently banned it as a therapeutic approach in 2015. 

In one case study, a child assigned male at birth, referred to as Kraig, had been expressing feminine traits and actions since the age of 2.

This included dressing in feminine clothing, using his mother and grandmother’s cosmetics, and expressing the “subtle feminine behaviors of an adult woman.” Researchers at UCLA, George A. Rekers and O. Ivar Lovaaz, who ran the study claimed that Kraig had an “overly dependent relationship with his mother”, and instructed her to ignore Kraig when he played with feminine toys, to demonize the actions.

Rekers and Ivar Lovaas

A system of reward and punishment was also implemented as part of the study, which escalated to candy rewards if Kraig expressed masculine behavior, or beatings from his father when he expressed feminine behavior (Bronstein and Joseph). After nearly 2 years, the study concluded, claiming the videotapes of Kraig before and after the experiment were “two different boys.” Although Kraig continued his life as a man, the traumatic effects of the treatment were undeniable, thought to have led to his suicide at age 38. 

Around the same time as Rekers and Lovaas executed their experiment in the late 1960’s, Dr. Harry Benjamin, a transgender man and physician, became one of the first prominent doctors to focus on accepting one’s transgender identity, rather than trying to change it. The publishing of his book, detailing gender-affirming surgery, coincided with the opening of John Hopkins University (JHU) Gender Identity Clinic, inspiring many similar initiatives in schools and hospitals. By 1979, an estimated 4,000 individuals had undergone some sort of gender-affirming surgery (Brody). He also had a large effect on the transgender youth population at the time, as he became extremely well known due to his unfamiliar methods of treatment. In 2021, Jules Gill-Peterson, a professor at the University of Pittsburgh, uncovered records from as far back as the 1930’s and 40’s, that demonstrated that transgender kids have existed for more of history than people think. Letters from the 1960’s and 70’s are addressed to Dr. Benjamin, requesting hormones and permits to dress as the opposite gender (Levin). However, at the time medical transitioning and gender-affirming surgeries were limited only to adult populations, as most doctors required individuals to identify as transgender for multiple years, and often throughout childhood, before considering medical care. 

It is worth noting that Dr. Benjamin’s studies have been viewed controversially by the medical and transgender communities. His definition of a transgender person was based on the idea that they sought medical transition, which is not always true for every transgender individual. He also based his decisions on who should have access to this care on his personal judgment of those who might possibly regret it, and those who had an

“unshakable internal gender identity”

Velocci

This standard for deciding who had access to care may account for why much of Dr. Benjamin’s research resulted in positive psychological outcomes for transgender people, similar to the majority of research being produced at this time. 

However, a 1977 study published by Jon Meyer, a psychiatrist at JHU, changed perspectives, triggering the closing of multiple clinics, including JHU’s in 1979. Meyer studied the long term effects of gender-affirming surgery on 50 individuals, eventually becoming convinced that being transgender was in fact a mental illness that could only be treated by psychological means (Meyer et al.). He published his findings, claiming that,

“this type of surgery [does not] cure psychiatric disturbance…We now have evidence that there is no real difference in the [transgender person’s] life…these patients have severe psychological problems that don’t go away following surgery.”

Transgender Map

John Hopkins University did not resume transgender healthcare services until 2017, a decision for which many transgender advocates blame Meyer. 

As a result of the increased awareness of transgender identity, in 1980, the third Diagnostic and Statistical Manual of Mental Disorders (DSM-III) was published, containing for the first time, information about “gender identity disorder”. The DSM is a book from the American Psychiatric Association that provides guidance for mental health professionals in recognizing symptoms and diagnosing patients with mental health and brain-related conditions and disorders. In the DSM-III, the new gender identity disorder section was split into three subcategories; transsexualism, non-transsexualism and not otherwise specified. The main “features” of transsexualism, as stated in the DSM-III, included “persistent discomfort…about one’s assigned sex in a person who has reached puberty.” This definition more clearly aligns with what is commonly known today as gender dysphoria, oftentimes a criterion for young people receiving GAMC. Gender dysphoria is a term used to describe the distress and anxiety an individual may feel if they are uncomfortable with not only their body, but their gender as it is perceived by others and oneself. Most individuals who identify as transgender experience gender dysphoria at some point, but the extent of it may vary amongst individuals. Not all individuals who experience gender dysphoria will identify as transgender, as it may gradually lessen due to a variety of factors. Another criterion for diagnosis was “persistent preoccupation [pertaining to gender identity], for at least two years”. Still today, medical professionals will often treat transgender patients only after evidence of their identity has been shown over a period of time, whether it be since childhood or several consecutive years. However, this standard has received pushback more recently, as more youth are attempting to access GAMC. The World Professional Association for Transgender Healthcare (WPATH) is an organization committed to clinical and academic research in order to advance evidence-based research in the field of transgender healthcare (WPATH). It was founded in 1979, and each decade since, they have released Standards of Care to guide transgender healthcare providers. Most recently, they released their eighth Standards of Care (SOC8) draft for public comment, they were met with disagreement from medical providers and transgender activists; specifically over a line in the new adolescent chapter stating that transgender youth should provide “several years” of persistent evidence that they identify as another gender (Bazelon). The reasoning for this was to draw a distinction between those who had more recently identified as transgender, because they could be more at risk for detransitioning and regretting medical intervention in the future. The most recent edition of the DSM, DSM-V-TR, was released in March of 2022. This edition refers to what used to be called “gender identity disorder” as gender dysphoria, in hopes to reframe the condition from a mental disorder to a brain-related condition. Referring to gender dysphoria as a disorder also carries an added stigma, implying something is “disordered” or fundamentally wrong with individuals who meet the criteria. Other text revisions were also made from the DSM-V to the DSM-V-TR, including updates to make language more “culturally sensitive.” This includes changing “cross-sex hormone treatment” to “gender-affirming hormone treatment”, and “natal male” and “natal female” to “individual assigned male at birth” and “individual assigned female at birth” (APA).

Although transgender identity is usually no longer viewed as a mental disorder, there is an undeniable relationship between transgender individuals and increased mental health risks. Transgender youth are considered an especially vulnerable population, evident by the alarmingly high rates of mental health issues and suicidal ideation among them. The Trevor Project conducts an annual survey to collect data about the mental health and well-being of LGBTQ+ youth, one of the largest initiatives in the U.S attempting to learn more about the health of this population. Results from the 2023 survey, containing over 20,000 responses of LGBTQ+ youth ages 13-17, state that 56% of transgender boys and 48% of transgender girls seriously considered suicide in the past year. Transgender youth are also at increased risk for anxiety and depression, as the survey reported 75% of transgender youth expressed symptoms of anxiety, and 60% expressed symptoms associated with depression (Trevor Project 2023 Survey). Although mental health is a major concern for all adolescents in the U.S., data from the CDC reported that 7% of cisgender youth had attempted suicide in 2019, compared to 29% of transgender youth.

As adolescents, transgender youth have the added challenge of going through larger life transitions while they simultaneously deal with challenges stemming from their identity. Approximately 40% of LGBTQ+ youth actively avoid bathrooms and locker rooms in their schools, and 20.9% reported frequently hearing negative remarks about transgender individuals from classmates, including slurs (GLSEN National School Climate Survey 2021). Not only do they often feel uncomfortable around peers, but many youth also report their teachers and school staff have made similar remarks, which sometimes affected their ability to learn in the classroom setting. While bullying is also a major issue for many adolescents, 43% of transgender youth reported instances of bullying at school, compared to 18% of cisgender youth. 

In the past few years, an increased amount of legislation surrounding transgender youth has been introduced into state and federal legislatures across the U.S. These bills range from preventing minors from accessing gender-affirming medical treatments, including puberty blockers and hormone therapies, to not allowing them to play on sports teams that align with their gender identity. The effects of hundreds of pieces of anti-transgender legislation being introduced each year is twofold. For transgender youth living in states where the legislation takes effect, many have a harder time finding doctors and GAMC facilities that are legally allowed to prescribe medications for minors, causing them to either forgo treatment, or travel farther distances to receive it. Although there are some states where anti-transgender legislation has failed to pass, transgender youth in these areas are still affected by legislation passed in other states, and the overall political and social climates it creates. 93% of transgender youth worry about GAMC being declined or unavailable due to new restrictions, causing another source of anxiety for this population. 

In Utah, the past year has seen an increase in anti-transgender legislation becoming law, including a bill that banned minors from playing on sports teams that align with their gender identity rather than biological sex. Mental health therapist Marisa McPeck-Stringham specializes in care for transgender teenagers in Utah, but her concerns have grown as more bills are being introduced to the state legislature. In an interview, McPeck-Stringham discussed how six of her clients have expressed feelings of suicidal ideation, all stemming from the state legislature moving forward with a bill to prevent minors from accessing GAMC, which was signed into law on January 28th. She worries about the future of her clients, and the possibility of them acting on their suicidal thoughts, which informs her methods of care, which includes developing safety plans with her clients to avoid an attempt at all costs (Rummler).For many transgender youth, both knowing that their identity is accepted, and having access to GAMC, can reduce rates of mental illness. Data from the Trevor Project claims that, “LGBTQ youth who live in a community that is accepting of LGBTQ people reported significantly lower rates of attempting suicide compared to those who do not.” (Trevor Project) This provides further evidence to support the idea that acceptance of LGBTQ+ identities can be life-saving for many. I’d like to now pivot towards the ethical aspects of using puberty blockers and HRT for transgender adolescents with gender dysphoria. A 12 month follow up study from Tordoff and colleagues collected data about the mental health of transgender youth from ages 13-20 before and after receiving puberty blockers or gender-affirming hormone therapy. Compared to the control group that did not receive any medication, 60% lower odds of depression and 73% lower odds of suicidality were observed, concluding that puberty blockers can have positive short term effects on individuals mental health (Tordoff et al.).

To reiterate, the goal of this paper is to conclude with an argument to answer my main ethical question; At what age should transgender youth be allowed to undergo medical transition, including puberty blockers and hormone therapy? To examine this question, I will be utilizing two ethical frameworks, consequentialism and virtue ethics. Consequentialism is a framework that defines the most ethical decision as the one that produces the most positive consequences, in this case, for the stakeholder who is the transgender youth. Virtue Ethics, on the other hand, focuses on one’s moral character, and ability to act ethically without external influences. Whereas consequentialism is a more universally applied framework, virtue ethics is a more individualistic framework, as the goal is for an individual to build “virtuous” habits with experience. When examining this question through the framework of consequentialism, transgender minors are the main stakeholder. When using virtue ethics, the main stakeholder may vary between the parent and the medical professional, as both need to act with virtuous intent to best serve the transgender child.

Consequentialism

Most universal standards use a consequentialist approach, as they base their opinion on the known majority of transgender youth who benefit from GAMC, rather than the more unknown amount of individuals who may detransition. Both the American Academy of Child and Adolescent Psychiatry and American Academy of Pediatrics express support for gender affirming care for adolescents on the grounds that without it, the mental health effects can be detrimental. Both organizations also emphasize the importance of family and youth working hand in hand when considering this care, to produce the most positive result for everyone involved, including a positive family relationship. 

However, an opposing argument to support consequentialism would prioritize the child’s future in terms of medical care and physical risk, as well as the multitude of unknowns surrounding hormone therapy and the contested rates of detransitioning. Utilizing available evidence, this argument follows what is commonly referred to as a “wait and see” approach, which translates to waiting to provide GAMC until an individual reaches an age where there is more of a guarantee they will not regret their decision. This standard gives an individual a period of time to ensure that medical intervention is the correct decision for their body, both mentally and physically. It can also possibly reduce the risk of an individual starting medical treatment at a young age, but later stopping, by giving them more time to experience multiple stages of endogenous puberty. A debate amongst transgender healthcare professionals is the idea that puberty blockers may not be fully reversible, and they may lock adolescents into a pathway of medical intervention due to the effects they may have on bone density, even after they decide to stop taking them (Twohey and Jewett).

Individuals can still have options for medical transition if they continue to identify as transgender after puberty. HRT allows for individuals to take hormones associated with the opposite sex, with or without the prior use of puberty blockers. After the age of 18, surgeries can be administered to further physically transform one’s body if they desire. Although an individual may not be able to be perceived as the gender they identify as until they are older than 18, there are still options for transgender individuals if they do not receive puberty blockers at the start of puberty. In most circumstances, puberty blockers are administered during Tanner stage 2, the stage of puberty when secondary sex characteristics become visible in both males and females. However, most children start puberty before the age of 13, and although an individual may feel strongly about their identity and fear puberty at a younger age, they may end up being pleasantly surprised by the changes they undergo, and no longer express an interest in being the opposite gender.  

One could argue that medical transition should not be considered until after an individual completes Tanner stage 5, around the age of 15 in most females and males. This way, a child will have a better sense of whether or not they truly do feel comfortable and like their own self in their body, and they can then either seek GAMC or continue to live their life without the need for medical interventions. Another concern is the mental health concerns many transgender children experience when beginning puberty. If an individual does express mental health concerns surrounding puberty, proper psychological care should be provided, but medical care should be avoided. Some individuals begin puberty blockers during intense periods of depression or anxiety, but later realize the medication does not resolve these problems. Many adolescents simply struggle with these mental illnesses, and are looking for a cause and a solution (Respaut et al.).

Using these standards, both the happiness and the mental and physical safety of a child can be protected, while still respecting the idea that a child may continue to identify as transgender past puberty. However, it may brush over the importance of the child’s autonomy, and result in disagreements between parents and children. Some transgender adolescents may feel their parents or guardians are unsupportive of their identities when they decide to wait on accessing GAMC. This may result in higher rates of depression, anxiety and suicidal ideation. Also, although a parent may be acting in the best interest of their child’s safety, they also need to balance their adolescents’ growing desire for bodily autonomy. 

In order to produce the most positive consequences while simultaneously keeping in mind the relative mental harm withholding care may have on a child, the following considerations need to be taken by all involved medical professionals. A consequentialist framework would dictate a solution that varies from the usual “all or nothing” approach associated with allowing transgender youth to access GAMC. Rather than the misconception that all GAMC is permanent and life altering, a physician would need to thoroughly explain the key differences between puberty blockers and HRT, specifically the fact that puberty blockers can be used as a pause for many transgender youth, but are also not without minimal risk, like most medications. While the argument is to prevent youth from accessing medication until they are sure of their identity, puberty blockers offer an option for a kid to relieve the anxiety of puberty when they truly are not sure of their gender identity. Waiting for a child to experience endogenous puberty and then evaluating the consequences can be incredibly harmful for many transgender individuals, as it provides additional stress, and complicates future medical transition if they choose to undergo it. 

While waiting until a child goes through puberty still allows room for an individual who continues to identify as transgender to medically transition at an older age, it renders puberty blockers virtually useless, and does not fully eradicate the possibility of an individual detransitioning, at any point in their lives. While considering a decision about life altering medical transition at the age of 15-16 rather than as young as 8-10 is much more reasonable, physicians and families are not considering anything that will likely deter the course of a child’s life at such a young age. Puberty blockers are a reversible drug in the sense that any effects they have on stopping one’s endogenous puberty can be undone once the use of puberty blockers is stopped. Endogenous puberty and development will continue. Beginning blockers also helps to create an easier transition to continued GAMC, including HRT. Having pre-existing relationships with this type of care and the medical professionals who provide it can help make it a more comfortable and less daunting process. In many cases, it also allows for increased satisfaction with one’s body post-puberty, as aspects of an individual’s sex assigned at birth are less likely to be visible. 

This is not to say that this care should be provided haphazardly. All transgender children should undergo a thorough intake and specified period of social transition before access to puberty blockers should be permitted. This prioritizes the mental health of the child, and could even be considered preventative care, as it may prevent a child from developing depression, anxiety or suicidal ideation associated with undergoing endogenous puberty. It also allows for time to still facilitate an open conversation surrounding one’s gender identity, and make decisions about the future of a child’s GAMC. 

By beginning the process with a thorough understanding of the patient, their family and their experiences thus far, the physician gets a better picture of whether themes commonly associated with gender dysphoria began more recently, or at a younger age and have developed over time. This can also help determine whether an individual may desist or continue to identify as transgender into adulthood. It also allows an individual to relieve possibly mental health issues, which may arise due to puberty, whether or not they do continue to identify as transgender. The key here is applying a thorough intake process before administering medication, rather than giving it right away. While some may argue it can create a greater toll on one’s mental health, in the long-term, it allows for individuals to access puberty blockers if their identity is unwavering, can prevent mental health risks from undergoing endogenous puberty, and creates a more seamless transition to further care while also eliminating the need for some possible future procedures.

Virtue Ethics

Another framework that may be utilized to examine this question is virtue ethics, a framework that prioritizes the intent and character of an individual, rather than the outcomes of their actions. Taking into account the oaths a doctor takes, universal intentions could include the intent to serve and help their patients, intent to relieve harm and suffering, and the intent to listen and take into account the thoughts of the patient. 

While many transgender individuals may transition later in life for a variety of reasons, this introduces a new set of surgeries and medical interventions, all which carry significant amounts of risk, possibly more than taking puberty blockers, and preventing the need for many of them, could do. By taking puberty blockers and then undergoing HRT, a transgender girl can eliminate the need for facial feminization surgery (FFS), a chondrolaryngoplasty, or shaving down of the adam’s apple, and removal of facial hair, because none will have developed. While a transgender person may not elect to undergo all of these procedures, most individuals seek more than just HRT when transitioning later in life. Starting estrogen at a younger age can help align a transgender girl’s growth in height with the distribution of body fat, and prevent them from growing as tall as some transgender women who start estrogen later in life, after they have undergone endogenous puberty and completed growth in height (Boskey). Similar benefits apply for transgender boys. Starting testosterone younger can help transgender boys grow as tall as cisgender boys, and develop body and facial hair. It can also prevent the need for a double mastectomy to remove breasts, as they are never given the chance to develop. Starting hormone therapies earlier can also possibly reduce the amount of time an individual needs to stay on them. Some transgender individuals decide they are satisfied with their physical appearance, and choice to stop hormone therapies during adulthood. 

Having more procedures creates more margin for risk, which can include increased susceptibility to certain cancers, infertility, weight gain and obesity. A virtuous physician would consider both reduced risk for possible physical harm, as well as reduced risk for possible mental harm in avoiding mental illness and suicidal ideation amongst transgender adolescents. A virtuous physician would also consider that every patient deserves to have their voice heard, and take into account a young transgender person’s request for puberty blockers or hormone therapy as equally as testimony from a parent or guardian. A virtuous physician would consider their ethical obligation to help relieve the suffering of all their patients, regardless of identifying characteristics, like being under the age of 18. The personal experiences and considerations of the patient should also be taken into account, as all patients should have a certain level of autonomy in medical decisions. Lastly, the focus should lie upon the most pressing consequence at hand, rather than the smaller, but still somewhat likely long-term consequences. These guidelines would eliminate specific standards or barriers for individuals with pre-existing mental illness or disability, as described in the consequentialist standards previously. It also focuses more on emphasizing the importance of youth autonomy, but focusing more on the idea that the patient is transgender rather than a minor.

Continuing to use the framework of virtue ethics, another argument can be formed against the previous. A virtuous physician is one who intends to protect a patient from physical harm, respects the autonomy of parents or guardians, and understands the limited capacity most children possess. Considerations for the age of the child, input from parents, and unknowns regarding puberty blockers and hormone therapy would be emphasized. 

There are still many possible negative consequences of puberty blockers, including bone density deficiencies, pseudotumor cerebri and other effects on the brain and development, and possible mental health implications associated with beginning treatment, or that do not subside during or after treatment. A parent’s perspective would also be valued, possibly over the child’s perspective, given that the child is not old enough to understand the future implications of medical treatment, and give proper informed consent for it. 

From this perspective, a virtuous physician would focus on protecting a vulnerable individual from physical harms associated with GAMC, which can be considered experimental in some cases given the many unknowns. The autonomy and importance of a parental perspective in this situation, as well as the autonomy of a family and their right to make personal decisions, would also be respected by a virtuous physician. Lastly, a baseline understanding that this decision can rarely be made by a child alone, considering their mental capacity and life experience, would be considered. Because of this, a parent is a much more suitable and legal decision maker, and carries the majority of the responsibility. It is also important for the parent and child to have a strong relationship with the physician, and for all parties to be on the same page regarding care.

In order to protect the child, the role of the doctor would include both educating as well as observing. Pediatricians are specifically trained to treat the general physical health of a child, as well as check in about emotional well-being. They tend to see their patients once or twice a year, meaning they can see developmental changes as they get older. For example, a pediatrician might be able to see a young, 3 year old girl who tends to prefer boy’s clothing grow up and have aversions towards developing breasts and starting her menstrual cycle. If the family inquires about transgender medical care or puberty blockers, the pediatrician has a better understanding of where this is coming from, as they have treated the same patient from infancy to adolescence. This also explains why some may be hesitant to provide resources and access to transgender medical care, because maybe there were no childhood signs commonly associated with being transgender.

While a virtuous physician has more of an intention to serve and educate, a virtuous parent may be one who prioritizes the safety and well-being of their child, while also taking into account their limited capacity and life experiences. Legally, parents have a responsibility to keep their child out of harm’s way, but many clash over how to best keep children safe. Should parents work to reduce mental health concerns and suicidal ideation by acknowledging their child’s gender dysphoria and allowing medical interventions, or protect them from making a possible poorly informed decision about may affect the trajectory of their entire life?

Given the variety of ages at which a transgender adolescent may seek GAMC, the ability for an individual to make a serious decision about medical treatment is a significant consideration. Legally, minors are not able to give informed consent, meaning they cannot make final decisions regarding their medical care, rather a parent or legal guardian has the final say. This requirement is based on the idea that individuals younger than 18 do not have the capacity to make larger, possibly life-altering decisions. However, there are some exceptions to this. In the US, there is a rule of law called the Mature Minor Doctrine, a rule of law that states a minor can be granted decisional autonomy by convincing a court they are mature enough to make a decision in their best interest. While not all minors are granted this privilege, some are, which shows that minors are capable of having the capacity to possibly consent to medical care, including hormone blockers. However, it is argued that at the age of which puberty blockers would have a potentially positive affect on an individual, children may not be equipped to give informed consent. The Endocrine Society agrees that “most adolescents have sufficient mental health capacity to give informed consent by…age 16,” (Kimberly et al.). Puberty blockers are only effective when administered at the onset of puberty, which is between ages 10-12 in most children. Although individuals of older ages, from 15-17, may be capable of making medical decisions like these on their own, that is not an overall generalization that can be made for all individuals. Most adolescents seeking access to this care are younger than these ages, and also juggling multiple other issues as well as their gender identity, which may affect their decision making capacity. 

A possible solution for these age discrepancies may involve putting aside one’s chronological age. Similarly to how people with intellectual and developmental disabilities (PWIDD) are given estimated mental ages, oftentimes younger than their chronological age, it may be possible to estimate the inverse among younger populations who express increased maturity. Using this system as a measurement for capacity could allow for more flexibility among transgender adolescents who desire access to GAMC, and it would eliminate the need for specific age limit recommendations, which are often inaccurate due to variations in when puberty begins.

In order to determine if an individual does have a proper developmental age, I have developed the following criteria to be considered: 

1. Ability to understand the long-term effects of their actions. Does the individual have a fundamental understanding of the changes and effects puberty blockers and/or hormone therapy can have on their body, their brain, and their future medical visits? Do they accept the fact that there are many unknowns associated with this care, which add a risk factor? 

2. How long has the individual identified as transgender? Individuals who meet gender dysphoria criteria from a young age may display a biological basis for their identity, determining if they will continue to identify as transgender into adulthood. For individuals who newly identify as transgender, but meet the criteria for gender dysphoria, a period of at least six months to one year is necessary to ensure stability within their identity. 

3. Are there any possible conflicting conditions that would affect their capacity to make medical decisions, or influence their gender identity? This could include intellectual disabilities, such as ADHD, autism and down syndrome, as well as mental illnesses with more harmful consequences, including history of suicide or self-harm, manic and psychotic episodes, and post-traumatic stress disorder. It could also include physical or sexual abuse related to their gender, which created discomfort with their body, or experiences of gender discrimination. 

4. Does the individual have a support system? Do they currently live in an area where other occupants respect and understand their identity? Do they have a positive relationship with their family? Individuals who do not have any sort of support system are less likely to be recommended for GAMC due to a larger risk of detransitioning. 

These standards could be used to assess both one’s developmental age as well as their environment and past experiences, all of which would factor into a decision as to whether or not an individual has the ability to consent to GAMC. Due to the importance of receiving puberty blockers during childhood to improve future gender affirming medical interventions, some argue that respect for childhood autonomy should be emphasized, as the same results would not be possible at the age of 18 (Abel). In a 2021 study from the Netherlands, 74 transgender adolescents between the ages of 10-18 were surveyed, 89.2% of them were found competent to consent to pubertal suppression. Four major criteria were assessed; “(1) understand the information relevant to one’s condition and the proposed treatment; (2) appreciate the nature of one’s circumstances, including one’s current medical situation and the underlying values; (3) reason about benefits and potential risks of the options; and (4) be able to express a choice.” (Vrouenraets et al.)

Although a child may seek medical interventions to affirm their identity, they cannot legally do so without parental consent and involvement in the process. Many medical professionals in the field of transgender medicine emphasize the necessity of having a strong support system, and a team to support the child during medical transition, including the utmost support from parents and guardians. A study from Dale and colleagues concluded that, “decisions about [gender affirming hormone therapy] GAHT are much more about gender identity than medical risks”, making it different from most pediatric medical decisions (Daley et al.). As a parent there are multiple considerations that make this a complex decision. Firstly, the physical health aspects, as well as unknown consequences of these medications in the long-term. No parent wants to put their child in harm’s way, or have them undergo a treatment where the results are still unknown. Some parents may also believe the possible physical risk outweighs mental health concerns, leading into a second consideration, the presence or development of mental health issues. If a child is already experiencing symptoms of mental health issues due to their body and development, it pressures the parent to make a quicker but possibly less educated decision. There may also be concern that a child will resent and blame their parents if they do not allow them access to GAMC. Some parents might feel pressured into saying yes, as they worry about the possible strain on their relationship with their child and family. Media portrayals of transgender healthcare and individuals also play a large influence in these decisions, as was evident by the case involving Dr. John Money. Depending on where information is coming from, implicit biases are almost always present, which may inform a parents opinion. 

Some parents look down upon or reject the idea of being transgender all together, whether due to personal or religious beliefs. In some situations, this may prevent or make it unsafe for an adolescent to socially transition, usually seen as a first step towards medical transition. Later down the line, if these individuals attempt to seek GAMC, they may be denied or questioned by doctors for not transitioning sooner, or made to wait longer for medical interventions, and go through a period of social transition at an older age, when physical characteristics may complicate the process. Not only does being forced to keep one’s identity a secret due to an unsafe environment create the opportunity for increased mental health concerns and suicidal ideation, it may also complicate medical transition. 

A vital part of many pediatric medical decisions is the importance of a strong relationship between the parent, the child and the medical professional. The medical professional may also influence a parent’s decision, depending on how they present information and treatment options. Depending on their wording, attitude towards treatment, and personal biases, a parents decision can be skewed. Many families come into these situations without much education about gender affirming medical care, or carrying a lot of misinformation. Given these factors, how should medical professionals approach informing and providing GAMC to children and families? 

Suggestions are often broad and encompass a wide variety of standards, making them challenging to enforce. An article from the American Family Physician suggests that all identities are “culturally variable”, and intake and exams should be “sensitive and tailored to the reason for each visit.” (Klein et al) Customizing care and the approach one takes to discussing medical transition options for every patient is not always feasible for medical professionals, especially those who work at gender clinics with extremely long patient waiting lists. However, more transgender healthcare specialists are pushing for individualized over collectivized care, which provides a better quality of patient care, but requires increased time and effort. 

Oftentimes, collectivized care can result in ignorance and in some cases, traumatic experiences for transgender patients. Negative experiences related to medical settings during youth can later affect a transgender adult’s trust and faith in the medical system, causing many to avoid doctors and hospitals for any type of care. Many parents may feel personally attacked or targeted by explicit judgements from medical professionals regarding their decisions, as most adults agree that every parent has the right to parent their own child. While a psychologist may emphasize the importance of puberty blockers after multiple intake sessions with a patient to protect their mental health, if a parent disagrees, does the medical professional have any obligations to the child? While a transgender adolescent may argue yes, both parents and politicians strongly believe the opposite. In a case where the parent and child disagree on treatment options, workarounds like the Mature Minor Doctrine may be applied, although most individuals wait until they are 18, and can legally consent without parental permission.

Responsibility of the Medical Professional

As outlined before, one of the main responsibilities of the medical professional is to provide clear, concise and unbiased information to a child and their parents regarding GAMC, and treat each patient specific to their unique needs. Rather than treating the condition, or alleviating gender dysphoria for transgender youth, the focus is on treating the individual. An article from Hädicke and colleagues focuses on the ethical question of “Is it primarily relevant that minors are involved? Or should decision makers focus on the fact that they treat transgender individuals?”. The paper explores the opinions and processes of psychotherapists, endocrinologists, gynecologists and more physicians who work with transgender youth. Two psychotherapists cited the importance of respecting the child just as much as any adult, if not more, and respecting their identity by inquiring about pronouns and gender preferences. An endocrinologist emphasizes the differences between each patient and family, but claims patient views should not always be utilized in the decision-making process, especially surrounding medical interventions for children. They claimed, “Well, it’s nothing minor, just when someone is eight years old compared to someone who is 18 years old.” Many doctors share the same sentiment. Lack of brain development severely limits the abilities of a child to make a fully informed decision. There are inherent vulnerabilities associated with children as well, including their reliance on parents or guardians for financial support, and the insufficient knowledge of a child compared to an adult. A child’s ability to think abstractly, reason, make proper judgements and understand their own personal values is still developing, which leaves them dependent on their parents (Hädicke et al.).

At the age of which puberty blockers would be effective, most children have never had the opportunity to make such a serious decision, and most of the time, they don’t have the ability to either. Although an adolescent may have more life experiences to draw upon, their ability to make complex decisions, such as those regarding HRT, are still developing. An adult, on the other hand, has a lifetime of practical knowledge to inform their decisions. 

Perry Ann Reed, a clinical ethicist and the executive director of WakeMed Children’s Hospital in Raleigh, North Carolina, discussed one major difference when considering medical treatments for adults compared to minors. In the 2019 Conversations in Bioethics panel, Reed compares the “dyadic relationship” (37:17) between an adult patient and doctor to the “triadic relationship” (37:23) of a patient who is under 18, their parents, and the doctor. Reed also uses a system of 7’s to determine the amount of input a child usually is capable of having in a medical decision. Children from ages 0-7 are usually unable to consider the extent of possible consequences in a decision regarding their health, meaning that a decision is made between parents and doctors who believe they are acting in a child’s best interest. From ages 7-14, although a child still cannot give informed consent, Reed believes a child is more than capable of giving assent, (a precursor to legal informed consent), than most people believe. In the case of GAMC, this would mean a child in most cases should be given the chance to make a decision regarding medical treatments, given that they understand the risks outlined by the doctor. 

Some physicians and advocates agree that the belief that most children are incapable of making decisions is due partly to the idea of age discrimination, a topic often brought up when discussing the elderly. Age discrimination is the practice of treating someone differently solely based on their age, like how both young children and older individuals are viewed as more vulnerable populations in society. Although they truly may be at higher risk for physical harm due to their stage in life, Lippert-Rasmussen and Hellman argue that children inherently having less power than adults renders their opinions and thoughts less important. Because of both age discrimination and discrimination against transgender individuals, the paper concludes by highlighting the need for intersectional approaches for treating transgender youth, similar to Reed’s idea of allowing the child a larger say in important decisions, even if it does not count as legal consent. However, some physicians believe children should not be allowed to make medical decisions, or receive GAMC at all. But some may feel pressured into providing the care, due to a variety of reasons, including social stigma and risk for their reputation. Medical professionals who do deny a transgender adolescent access to medical care, for any reason, may be quick to be judged, and labeled as a “transphobe”, or an individual who does not support transgender individuals or GAMC. Although their concerns may be valid, for example if there is a link between mental illness or physical trauma and gender identity, some medical professionals may fear the consequences to their reputation if they refuse care. A former employee at the Washington University Transgender Center at St. Louis, Jamie Reed, detailed the lack of “formal protocols” in prescribing medical transition related to care for transgender youth. She believed the involvement of parents should have been at the forefront of treatment, but in Missouri, only one parent’s consent is required to go through with treatment. According to her testimony, the clinic almost always sided with the parent who argued for GAMC. Her concerns also extended to the intersection of mental health and transgender identity. Many of the patients who presented at the clinic, 50-70% of them individuals assigned female at birth, had many other pre-existing conditions, including depression, anxiety, ADHD, eating disorders and autism or autism-like symptoms. When Reed brought up the idea of their gender identities manifesting as a result of their mental conditions, her concerns were brushed off, as doctors claimed “gender identity reflected something innate.” This statement is not entirely true, as there is not a conclusion amongst researchers and scientists that a biological basis for transgender identity does in fact exist, albeit the evidence provided by cases like the John/Joan Study. Almost all patients were referred to the same therapist to receive letters of support to begin their transition, and after one or two visits, patients could be given puberty blockers or HRT. Reed believed more precautions should have been taken for children with existing mental conditions, especially those already receiving other medications to treat their conditions. One parent revoked their consent for a hormone blocker after their son was put on five different medications to treat various mental illnesses (Reed).

Is it really doing no harm to medically intervene during a period of crucial development in a minor? Should further considerations and regulations be put into place for transgender youth with mental illnesses? On the one hand, it may protect against medical harm for children who later detransition, but on the other, it may also further exacerbate discrimination against individuals with mental illnesses. 

Although Reed discussed the lack of formal standards at the clinic she worked at, this must be balanced with the idea of patient-centered, individualized care. A compromise has to be made, somewhere in the gray area between universal standards for all transgender healthcare professionals and providing no clear information regarding how decisions are made for transgender youth.

Professional Autonomy

In Reed’s condition, as well as the state of many other healthcare providers across America who have transgender youth presenting in their practices, a debate over professional autonomy is also emerging. Simply put, should a medical professional have to provide care they may not personally agree with? This argument is commonly brought up in conversations surrounding other controversial issues in bioethics, namely abortion and Medical Aid in Dying (MAID). When asked to provide this type of medical assistance, as when asked about medical transition, many doctors may refuse to offer these options to their patients because they feel it goes against their personal morals, and obligations as stated in the Hippocratic Oath. Providing an abortion or lethal drugs for a patient could be viewed as a violation of the idea of doing no harm. Just as in other discussions around GAHT, some physicians see this medical assistance as avoiding harm, and doing good for their patient. Similarly, providing an individual with either puberty blockers or HRT can result in physical harm. However, the more common argument is for professional autonomy, as some medical professionals refuse to provide either treatment simply because they do not agree with the idea of a child making possibly life-altering or irreversible physical decisions, and they do not support or uphold the existence of transgender individuals. While the idea of transgender identity being defined as a mental condition was eradicated in the DSM, some individuals continue to believe it is in fact a mental condition that needs to be treated solely through psychological means rather than physically. Should medical professionals with conflicting beliefs be allowed to opt out of providing puberty blockers or HRT? 

In 2022, the 5th U.S. Circuit Court of Appeals ruled that health care providers may opt out of procedures such as abortions or medical transition care, with no consequences, if it violates their religious beliefs (Shepherd). The case did not allow for hospitals and medical professionals to outright refuse to care for transgender individuals, but specifically to refuse GAMC. Eighteen and a half percent of hospitals in the U.S. are religiously affiliated, meaning they could potentially opt out of providing GAMC, utilizing religion as a defense. This case raises a larger question for religious medical professionals; Should becoming a doctor mean signing over one’s religious beliefs in the workplace in order to provide the best possible care to the patient? Allowing one’s religion to play a role in their course of action for patient care may result in biased care and information, but should an individual be expected to leave all personal aspects of their lives at the door before entering the workplace?

As disputed as the role of the physician is in providing GAMC, the role of both state and federal governments is arguably even more prevalent, especially given the rise of legislation across the U.S. restricting access to GAMC for minors. In Arkansas, state Representative Robin Lundstrum was the lead sponsor for the SAFE Act, or Saving Adolescents From Experimentation Act. The SAFE Act passed in April of 2021, and banned GAMC for all minors in the state of Arkansas. In an interview, Lundstrum clarified that the goal of this bill is not to take away healthcare for transgender youth, it’s simply to avoid medical interventions. She emphasized the importance of counseling and mental health care, rather than treatments that could be considered experimental, especially during adolescence. She also claimed it was not a legislative overreach to do so, because both puberty blockers and HRT are off-label uses for the drugs, and they should be regulated because of this. (Allen and Evans).

The involvement of Lundstrum, as well as many other politicians, raises concern over where the roles of doctors and the roles of governments meet, and if they should overlap. Some physicians, like Dr. Cantor, who provided the expert witness defense to support the criminalization of GAMC in Texas and Alabama, believe the government should have a role in regulating this care, specifically because it affects families rather than individual patients. However, others worry about the precedent this sets for other types of medical care, as it allows for the government to regulate the care, sometimes without the input or opinion of doctors. 

In many states, the political climate surrounding GAMC discourages many families from allowing their children to socially transition and access medical transition. Similarly, many doctors also worry about the consequences of providing this treatment to minors, as it could result in imprisonment in some states.

The financial accessibility of GAMC is yet another factor that plays into many family’s decisions to begin treatment. Dr. Travers, a professor of Sociology at Simon Fraser University, wrote an article about the emerging “classes” forming amongst transgender youth. One class has relatively easy access to GAMC, while the other does not, due to factors including socioeconomic status, geographical location and insurance status (Travers). 

Regardless of healthcare insurance, GAMC can still carry a hefty price tag. Puberty blockers can cost several thousand dollars with insurance coverage, and anywhere from $5,000 to upwards of $30,000, depending on the type of blocker, when paying out of pocket. However, the list price, given here, is often cheaper than the final price. One family was attempting to get their daughter started on puberty blockers because she had been diagnosed with CPP. The estimated bill was $95,000, not including the cost of implantation. Even with insurance, he was still worried about the cost, which would end up around $18,000 – $20,000. Without insurance, the full $95,000 would need to be paid out of pocket, which is rarely feasible for the average American family. 

Endo is one of the main manufacturers of Supprelin LA, an FDA approved histrelin implant for treating CPP, but also commonly prescribed for transgender youth as a puberty blocker. In 2020, Endo halted production of Vantas, another histrelin product seemingly identical to Supprelin LA, with FDA approval for treating late stage prostate cancer. Both implants contained 50 mg of histrelin, and Vantas released 50 mcg/day while Supprelin LA released 65 mcg/day (Lupkin). In a study by Olson-Kennedy and colleagues, both products resulted in the same halt of unwanted secondary sex characteristics, yet their prices remain drastically different (Olson-Kennedy et al.). Vantas, the cheaper but now discontinued product, had an average list price of $4,400 while Supprelin LA has an average list price of $37,300. Without lower cost alternatives, many families are forced to pay outrageous fees out of pocket, fees which many families cannot afford. 

According to the Transgender Legal Defense and Education Fund (TLDEF), virtually all insurance companies recognize that GAMC is necessary, but depending on what policy an individual has, it may or not be included. While many companies include gender-affirming surgeries in their policies, puberty blockers are not as commonly included. Fertility preservation options are also rarely included in policies, which can be extremely costly as well (TLDEF). While transgender individuals are often made aware of the fact that their treatment could result in infertility, fertility preservation options are extremely inaccessible, even for individuals with insurance who are not transgender. For individuals assigned female at birth, oocyte cryopreservation can allow for retrieved eggs to be frozen and saved for later use. The entire cycle, including medications, blood tests, ultrasounds, and the egg retrieval procedure, can cost anywhere between $6,000 and $10,000. After the procedure, eggs need to be properly stored in a facility, which can cost about $600 per year (Grace Merkley). Most insurance plans only cover fertility preservation in a situation where an individual has a condition that causes infertility, which would leave transgender individuals and their families to not only make a decision about fertility before starting HRT, but also having to factor in the overall cost and necessity of preserving their child’s future fertility options. 

State Medicaid policies have moved towards including GAMC, but it varies by state. Eleven states, including Arizona, Alaska, Wyoming, Nebraska, Texas, Missouri, Arkansas, Tennessee, Georgia, Ohio and West Virginia, exclude gender-affirming healthcare from state Medicaid policies. 17 states do not provide explicit details as to whether or not gender-affirming healthcare is covered, and 22 states and D.C. do cover it under state Medicaid policies.

Majority of the states where Medicaid policy excludes or is unclear about gender-affirming healthcare are also actively considering or passing legislation to ban the practice of providing gender-affirming healthcare to transgender minors. Three states are attempting to ban gender-affirming healthcare for adults as well, in Oklahoma, anyone under 26 years old, and in Virginia and South Carolina, anyone under 21 years old. New legislation adds another challenge for transgender youth attempting to access GAMC, as it requires individuals to either explore illegal means to care, or travel to other states to access care.

Gender affirming care for transgender youth has become an increasingly more politicized issue in recent years, causing controversy over new research and studies. No one is quite sure where to draw the line between medical decisions and respecting family values, as many doctors believe politicians have no right to involve themselves in medical issues, but others support these decisions and believe politicians have a duty to take into account the views of their respective jurisdictions. While most politicians are not experts on GAMC, should they have the power to mandate it in state legislators? And if not politicians, then who should be in charge of mandating this care?

Children begin puberty at various ages, from as young 9 years old to as old as 14 years old in individuals assigned male at birth, and in individuals assigned female at birth puberty can begin as young as 7 ½ in some cases, to as old as 14 years old (Cleveland Clinic). Most individuals will reach Tanner stage 5, or the final stage of puberty, around age 15, but this may vary depending on how early an individual begins puberty. The life experiences, capacity to understand and general knowledge in an individual differ greatly between ages as young as 8 to as old as 15, implying that a strict age limit may be nearly impossible to determine and apply in universal standards of care for transgender youth.

Providing GAMC for transgender youth needs to be an individualized process, and one that focuses on both positive outcomes for patients, as well as the intentions of the physicians providing this care. Ultimately, patient-centered care has the most possibility for positive outcomes, and requires a doctor to properly consider their patient and the available options. Although it may require more time and effort on behalf of the doctor, it overall results in a more informed patient-physician relationship, which will ultimately yield the best possible care for transgender youth, as proper consideration can be taken for both the values of safety and autonomy. One’s definition of safety can vary greatly, and an individual may choose to prioritize their physical or mental health above one another, but not every patient is the same. It also allows for more focus needs to be put on the developmental level of a child, as oftentimes one’s chronological age is not enough of a factor to determine their capacity. 

 To quote Perry Ann Reed, “[Children ages 7-14] can make more decisions than people realize” (39:03). Utilizing her system of 7’s, one could argue that laws barring all minors from accessing GAMC are unethical, as it would not be right to assume all children cannot make important medical decisions that may affect their future. However, there is also a reason why minors cannot legally provide consent for medical procedures. They lack the same life experiences and mental development as adults, which may cause them to make more impulsive or uneducated decisions, without fully grasping the weight of the consequences.  

Although many American organizations support early medical treatment for transgender youth, this is not universal amongst all countries. France, Australia, New Zealand and the United Kingdom all lean away from the idea of early medical interventions for transgender youth, implying that youth autonomy is generally a more “American” idea. Similarly, the culture of our society works against the idea of individualized care, as most patients are often seeking a quick fix and short term satisfaction. 

In providing individualized care for each transgender patient who presents to a gender clinic, appointment waitlists will inevitably increase, as well as the frequency of appointments necessary for a doctor to truly get to know their patient. However, in a rapidly developing, capitalist climate, the medical field is shifting more towards providing treatment rather than caring for patients, and raising concern about the intentions of doctors in their respective fields. Many individuals worry about the motivations of physicians and how they may affect the type of care a patient may receive, which may make it harder for comprehensive assessments to be made for transgender patients who require this very individualized care. 

Although there is not one universal standard for treating all transgender patients, overarching standards for how to approach and structure intakes and treatment with these populations are still important to help educate physicians, many of whom have never worked with or learned about transgender youth before. Organizations like the the World Professional Association for Transgender Healthcare (WPATH) and the Endocrine Society have released guidelines and standards for treating transgender youth, but there are changes that need to be made in order to ensure accurate information and feasible solutions are given to doctors.  

Gordon Guyatt, a professor at McMaster University in Ontario, co-developed the GRADE (Grading of Recommendations, Assessments, Development and Evaluation) system, which he used to analyze both the Endocrine Society and WPATH’s guidelines for transgender individuals. He determined that the Endocrine Society guidelines had, “serious problems”, most notably the fact that they contained no systematic reviews of the effects of medical intervention on gender dysphoria, arguably, “the most important outcome.” In WPATH’s guidelines, he identified that information included is supplemented by systemic reviews from Johns Hopkins, but the quality of the evidence could not be determined. Despite phrases of uncertainty, like how hormone therapy “may improve” mental health, and it was “impossible to draw conclusions” about the effect hormone therapy has on suicide, WPATH still recommends young people have access to medical treatments after comprehensive assessments. Recently in the U.S., the Florida Agency for Health Care Administration commissioned an overview of systematic reviews to look into mental health and quality of life outcomes for individuals with gender dysphoria. An analysis of 61 systematic reviews by two methodologists from McMaster University concluded there was, “great uncertainty about the effects of puberty blockers [and] cross-sex hormones…in young people.” 

““It’s important to have evidence-based medicine instead of expert opinion or just opinion at all,” van der Loos said. He is the lead author of a Dutch study where 98% of transgender adolescents continued to HRT after puberty blockers. Evidence about the rates of individuals who detransition later in life is very rare and often misinterpreted, due to a lack of information and various reasons for detransition. Many worry that the rate could be much higher than the current evidence-based 1%-2%, but it is unknown (Ghorayashi).

Based on these considerations, the following changes should be made to the WPATH SOC. Firstly, a grading system, similar to Guyatt’s GRADE system, should be utilized to verify and provide a measure of validity to readers. Due to many transgender studies being viewed as unethical or misinformative due to the nature of the research, there is often little general consensus on which studies to utilize as standards of care. Providing a grade of the study provided can help to determine how credible the information coming out of a study truly is. Another consideration would be to align concluding statements with evidence provided. If there are still unknowns and indefinite variables, the concluding guidelines should align with these undetermined results. By making these changes to the WPATH SOC, more accurate information can be provided to parents by medical professionals, which would aid in avoiding biases in patient care. Although the most informed decision may not always result in the decision with the most positive consequences for all parties, the intentions of a physician to properly inform a parent and/or child may contribute to a more thorough final decision.

Closing Statement

As contentious as the political climate is regarding GAMC, we have seen throughout history what ensues when something is banned by the government. Before abortion was enshrined as a constitutional right, illegal procedures were performed across the U.S. to aid pregnant women. During the Prohibition era, the banning of alcohol only led to an increase of illegal methods to produce and distribute it. Although it may be illegal to provide or access in multiple U.S. states, doctors and patients will still find ways to access this treatment. While this may not be legal, the ethicality of an action is not always based on the law. As a bioethicist, both considerations for the individual and for the larger population need to be taken into account when analyzing this issue. 

As an advocate for transgender youth and overall acceptance, my goal for this paper was to accurately represent all sides of the debate over gender-affirming medical care for minors. Not only did I want to better educate myself, but I also sought to inform others about the often ignored risks and benefits of this care, and get under the surface of an often black and white argument. 

With proper consideration, allotted time for social transition, and any other necessary precautions, I believe gender-affirming medical care should be provided for transgender youth. In some cases, this care can be life-saving, and according to available research, the potential benefits outweigh the margin for risk. However, this is not a decision that should be made lightly, or without appropriate deliberation. Children are inherently more vulnerable than adults, making any pediatric care an extremely complex and multi-layered issue, especially when there are unknowns involved. 

Ultimately, the ethicality of providing hormone therapy for transgender youth is dependent on the maturity and capacity of each individual, and their ability to balance risks and benefits in order to appropriately judge their safety.