Not just a tragic compromise: The positive case for adolescent access to puberty‐blocking treatment

Abstract

Within bioethics as well as in broader clinical practice, support for transgender and gender‐questioning adolescent access to pubertal suppression has often relied heavily on the desire to prevent risky, self‐destructive, and suicidal behavior. We argue that framing justifications for access to puberty suppression in this way can actually be harmful to both individual patients as well as to the broader trans population. This justification for access to care makes such access precarious, limits its scope, and introduces perverse incentives to the patient population that is being served. We go on to offer an alternative, positive defense of access to puberty‐blocking treatment for transgender youth grounded in the child's right to an open future. We argue that decisions related to pubertal suppression are both importantly weighty and potentially irreversible, and show why this justification is preferable to so‐called “informed consent” approaches.

Puberty Suppression for Pediatric Gender Dysphoria and the Child’s Right to an Open Future

“…He states, “[i]t is plausible to ascribe to children a right to an open future only in some, not all respects, and the simple formula leaves those respects unspecified” (Feinberg, 1980 , p. 77). While some have argued for a maximal interpretation of the right’s scope, which would imply all options that might permissibly be chosen by the autonomous adult be protected (Millum, 2014 ), a more moderate and pragmatic interpretation, whereby the future adult is able to choose among some “vital” interests that are important in determining one’s life course has been applied by many who cite Feinberg’s work (Darby, 2013 ; Davis, 1997 ; Garrett, 2022 ; Kon, 2015 ; Wenner & George, 2021 ). We can imagine interests related to pubertal development as rights with this vital quality.…”

“…A key rationale for puberty suppression in children with gender dysphoria is the recognition that physical changes associated with endogenous puberty are difficult to reverse, with transgender adults often undergoing expensive and invasive procedures to alter the sex characteristics they developed during puberty (Delemarre-van de Waal & Cohen-Kettenis, 2006 ; Wenner & George, 2021 ). Hormonal therapy and surgery in adulthood frequently fails to deliver desired cosmetic changes, especially for male patients, who have been described as having a “never disappearing masculine appearance” (Delemarre-van de Waal & Cohen-Kettenis, 2006 , p. S132).…”

“…It has also been suggested that living in the eschewed gender role during the formative years could contribute to the high rates the mental illness seen in transgender adults following medical and surgical transition (Cohen-Kettenis & Gooren, 1999 ; Delemarre-van de Waal & Cohen-Kettenis, 2006 ). As one commentator remarked, “[a]llowing puberty to progress unimpeded thus represents a partially irrovocable decision” (Wenner & George, 2021 , p. 929). In the context of the open future principle, not halting endogenous puberty could foreclose a child’s right to achieve their “gender embodiment goals.”…”

“…Therapeutic endpoints are also in flux. Whereas the primary goals of therapy at one time were to reduce gender-related distress, improve coexisting psychiatric symptoms, and prevent self-harm, some have argued that this framing pathologizes transgender identification and excludes those who are otherwise in good mental health (Ashley, 2022 ; Wenner & George, 2021 ). Moreover, the high prevalence of psychiatric co-morbidities in those with gender dysphoria is said to be a consequence of chronic stress produced by stigma and discrimination related to gender non-conformity and not indicative of underlying psychiatric pathology (Chodzen et al, 2019 ; White Hughto et al, 2015 ).…”

Transporting the Burden of Justification: The Unethicality of Transgender Conversion Practices

“…Allowing justifications of this kind would be tantamount to a bigot’s veto, aiding opponents of transitude in eradicating it. 45 A bigot’s veto is all the more unacceptable given the role of trans conversion practices in legitimating and perpetuating transantagonism and cisnormativity. It could perhaps be countered that conversion practices can be justified by sufficient transantagonism — for instance in countries that systematically put trans people to death.…”