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Can minors truly consent to reversible puberty blockers in gender-affirming health care?

Gender-affirming health care (GAH) is a rapidly developing sector within the medical profession that can include indirect therapies such as counseling, direct therapies such as hormone treatments, puberty blockers, or gender-affirming surgeries. A main ethical concern with GAH resides in its use on adolescents, and this paper will primarily explore the use of puberty blockers, sometimes called GnRH analogues, on minors.

Considering that most children start puberty around the age of 10 or 11, the age at which puberty blockers can be used for the greatest effect is almost always before the age of assent in minors (around age 15). Legal access differs widely between states, with some states not allowing the prescription of puberty blockers to anyone under 18, but guidelines from the World Professional Association for Transgender Health (WPATH) suggest the use of puberty blockers much earlier, as early as age nine in individuals who have attained Tanner Stage II. This raises the ethical question of whether minors can assent to and receive non-invasive puberty blockers.

This essay will consider the safety of puberty blockers in an examination of the common claim that they are fully reversible. This paper may not apply to all youth who are considering undergoing GAH, and special consideration for each individual will continue to be paramount for doctors who prescribe GAH to minors.

The Mayo Clinic guidelines for gender-diverse persons interested in starting puberty blockers state that “GnRH analogues don’t cause permanent physical changes. Instead, they pause puberty.” In the same section, a further claim is made: “When a person stops taking GnRH analogues, puberty starts again.” Similarly, the WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People lists “the use of GnRH analogues to suppress estrogen or testosterone production and consequently delay the physical changes of puberty” as “fully reversible interventions.” However, a general lack of evidence creates concerns about the certainty of these claims.

A 2017 essay on treating gender dysphoria concluded that “the evidence for the safety and efficacy of puberty suppression is thin, based more on the subjective judgments of clinicians than on rigorous empirical evidence.” While this paper is over six years old, the disturbing lack of evidence for the full reversibility of puberty blockers still permeates discussions today. Instead of new evidence quelling fears, three years ago the National Health Service (NHS) of England changed its statement on puberty blockers from endorsing their full reversibility to now claiming that “little is known about the long-term side effects of hormone or puberty blockers in children with gender dysphoria.” Notably, concerns with the development of brain tissue, bone growth, and psychological effects challenge the reversibility of puberty blockers prescribed to treat gender dysphoria. Despite claims of high certainty in the reversibility of puberty blockers, there is scant evidence that supports the nature of puberty blockers as fully reversible while more and more studies surface claiming the opposite.

The intentionality behind using puberty blockers to treat gender dysphoria greatly differs from the purpose for which puberty blockers were invented, which was to treat precocious puberty in children. Because of this difference, cases arise where puberty blockers are used outside their intended field and may therefore have unknown consequences. This is often the case when puberty blockers are used to treat gender dysphoria.

The fact that children with suppressed precocious puberty between ages 8 and 12 resume puberty at age 13 does not mean that adolescents suffering from gender dysphoria, whose puberty is suppressed beginning at age 12, will simply resume normal pubertal development down the road if they choose to withdraw from the puberty-suppressing treatment…

The use of puberty blockers to treat gender dysphoria remains a highly experimental field with little research to provide adequate justification for their widespread use. Claims of the full reversibility of puberty blockers should be taken with hesitation, considering that they are often the result of biased speculation. Until further research is undertaken to determine the safety of using puberty blockers to treat gender dysmorphia, the risk of wantonly disrupting the natural processes of the human body far outweighs the potential mental health benefits to those struggling with gender dysphoria.

Logan Vayder is a medical ethics student.

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