Lexi McGowan is double majoring in biology and public health with a minor in chemistry and is a 2022-23 health care ethics intern at the Markkula Center for Applied Ethics. Views are her own.
Gender Dysphoria occurs when there is a misalignment between the experienced gender of an individual with their gender assigned at birth. This incongruence with the binary can cause stigmatization, difficulties building relationships, poor self-esteem, and eventually depression and anxiety. It is important for youth to go through a psychodiagnostic evaluation to determine the presence of gender dysphoria and determine the best steps in moving forward.
This dysphoria typically presents itself during adolescence, and risks self-harm or potentially suicide. Passing through the “wrong puberty” is extremely harmful to youth and the development of their social relationships. The gender reassignment process improves this psychological health.
Delayed Transitions: Risks of Anxiety and Depression
Supporting children in their identities allows them to thrive. Puberty-suppressing gonadotropin-releasing hormone analogues (GnRH) are a reversible treatment option for early stages of gender dysphoria. Further along, there are also options for partially reversible treatments, such as gonadal steroid treatment, or surgical interventions (modifying/removing/reconstructing genitalia) which are irreversible.
Puberty suppressants allow youth to halt the development of secondary sexual characteristics. This prevents passing through the wrong puberty, and allows extra time for cognitive development and exploring their gender. One study on transgender youth who were allowed to socially transition found that levels of anxiety and depression among this group were not significantly different from those who were not transgender.
In another study, GnRH analogues were used among youth ages 12-16 years old. Psychological functioning and gender dysphoria were assessed twice: once before the start of GnRHa and once after, just before cross-sex hormones were introduced. They found behavioral and emotional problems, as well as depressive symptoms, decreased between the two measurements. They also found the natal females in the study were older when they began the process, and had higher levels at both time periods, compared to the natal males. This may indicate the value of beginning treatment at earlier ages.
A study on young adults who completed all three stages of transitioning found improvements in gender dysphoria, psychological functioning, and found their well-being to be comparable to young adults in the general population, specifically after reassignment surgery. Allowing youth to complete all stages of gender reassignment gives them the chance of successfully developing into adults with similar experiences and functionings of their peers.
The Risk of Changing Minds or Regret
It is often argued that it is wrong to begin transitioning youth before they reach the legal age of consent, and that gender dysphoria is simply a phase youth are going to pass through. However, when 55 transgender people were given puberty blockers during adolescence, the study found that no one experienced regret or changed their minds. Once puberty is reached, transgender youth are very unlikely to change their gender identity, which is when irreversible medical intervention can begin. Starting with puberty blockers would allow a buffer in the unlikely event one was to change their mind. Although importantly, another study noted that no adolescent stopped puberty suppressants, and all went on to begin hormone treatments.
The Safety of Medical Treatments
Another prominent concern of transitioning youth is whether or not the treatments are safe, and how they can impact physical health. The puberty suppressant implant is shown to have some mild side effects, including decreasing bone density. Luckily, once the implant is removed and hormone treatment is initiated, this quickly resolves itself.
Puberty suppressants and hormone therapy can impair fertility. A current solution is offering fertility preservation options, including freezing sperm/eggs so they can access them later on to build a family.
At a minimum, allowing hormone treatment while continuing GnRHa can allow the individual to go through puberty in alignment with their gender identity, and combat dysphoria, before taking on the obvious risks of surgical intervention. Forcing one to undergo the wrong puberty is far more harmful than the risks of early treatments.
Unfortunately, there are still limitations within the research surrounding the safety and efficacy of the use of GnRHa in children under the age of 12, and for hormone treatments in those under the age of 16. This is where current research needs to be focused, as many youth begin puberty before the age of 12.
How Young is Transitioning Ethical?
Not many years ago, the use of puberty blockers and starting hormone treatment would have been considered malpractice by doctors. Many adults share stories of how beneficial it would have been for their children to avoid going through the wrong puberty. But also consequently, the use of puberty blockers without hormones/surgery limits the individual from developing at the same rate as their classmates. This is why it is essential to begin treatments as soon as possible, especially puberty blockers and cross-sex hormones. Gender-affirming surgery should also be allowed to begin earlier, but this should follow the recommendation by medical professionals and a psychologist (as this is completely irreversible and significantly life-altering).
The four principles of ethics: beneficence, nonmaleficence, autonomy, and justice, are all relevant when considering the controversy of youth gender affirmation. Physicians must consider the risks and avoid causing harm to the patient, and it is also important to do what is best for the mental health, well-being, and development of the child by affirming their gender identity. Clinicians must help the individual in all ways possible with puberty blockers and hormonal treatments, as they are currently the safest developments available. This is the duty of beneficence. Failing to do so can have detrimental psychological consequences. In terms of justice, transgender youth have the right to go though the correct puberty, just as their peers do. Getting affirmed and accepted in their identified gender is a right, and all youth should have, and need, access to this.
Perhaps most prevalent in this discussion is the right to autonomy. The individual must have autonomy over what treatments they pursue and what they do with their own body. But the main issue is at what age should transgender youth be able to do this?
The current age for surgical procedures in the U.S. is 18. Hormonal therapy can begin when there is confirmed gender dysphoria and adequate mental capacity for informed consent, including an understanding of the risks, at age 16. Parental consent is also required for any treatments when the patient is under the age of 18.
I argue that delaying this treatment, even to 16, can become not only detrimental to bone health of the individual, but also harmful to their mental health by keeping them in a prepubertal state that inevitably leads to isolation and harm to well-being. I also argue that requiring parental consent, therefore possibly delaying treatment, can be detrimental to the subset of children who do not have this support.
Exceptions do not currently exist for children when their parents do not consent. Following the model of the UK, the courts should be able to overrule lack of parental consent if the treatment would be in the best interests of the child.
While children do not have legal power in decision making, it is important to look at this on a case-by-case basis, to initiate treatments as soon as they are deemed mentally fit to consent, as some youth develop, mentally and physically, quicker than others. This individualized approach will ensure the right decision is made for the specific child, as it will be in accordance with their age and maturity. Discussions of risks and advantages are crucial in this time period, and should begin even earlier to allow time for thoughtful analysis by the individual and their family.
Common practice needs to be allowing youth to begin transitioning genders when they feel ready, following a psychological consultation and evaluation, in order to improve mental health outcomes. In order to do this, more research is needed, and should be prioritized, for the youngest age that is medically safe to begin puberty blocker and cross-sex hormone therapy.