“We don’t let kids get tattoos”: Trans youth treatment, ethics, and decision-making

Previously: Transgender youth fact check, Debunking hypothetical arguments about youth transition

In the public conversation over the use of puberty blockers for adolescents with gender dysphoria, those who object to this treatment often express concerns about the ability of these youth to make such a significant medical decision. Such objections often call into question adolescents’ maturity and their capacity to understand potentially permanent consequences:

If a child is too young to drive a car, get a tattoo, vote, buy a drink at a bar, then they are too young to decide to make life altering decisions like transitioning. (YouTube user legacy1X, Apr 25, 2017)

Others emphasize specific impacts to these youth such as fertility loss, holding that this is unacceptable under any circumstances:

There is no good argument that allowing children to permanently modify their bodies and sterilize themselves is ethical. NONE. (YouTube user Blaire White, Dec 19, 2016)

While parallels to tattooing and other “life-altering decisions” might intuitively resonate for many, these superficial comparisons do not hold up on closer analysis, and do not reflect the expert consensus on the appropriate use of puberty blockers for trans youth. Potential ethical considerations and the importance of informed consent are recognized by professionals involved in the treatment of these adolescents, and these concerns have been addressed at length.

How puberty blockers are used for trans youth

Characterizing the use of puberty blockers as a “life-altering” or “permanent” decision inaccurately represents the treatment pathway followed by adolescents who are given these medications. Blockers are typically used near the onset of puberty, at Tanner stage 2 or 3, and temporarily prevent the further development of secondary sex characteristics, such as a deep voice and facial hair in trans girls or breast development in trans boys (Shumer & Spack, 2013):

Suppression allows time for the patient to socially transition to the desired sex and confirm the persistence of GID. In addition, adolescents with persisting GID often experience worsening sex dysphoria with the development of their undesired biologic puberty, and suppression can reduce this dysphoria. Finally, by suppressing puberty, the patient avoids irreversible body changes such as facial hair growth, voice change, an Adam’s apple and a male facial bone structure in boys [trans girls], breast development in girls [trans boys] and body shape changes in both sexes.

Adolescents can continue to take blockers until either choosing to stop, which allows their original puberty to resume, or starting cross-sex hormones (estrogen or testosterone) to induce the puberty of their desired gender with appropriate secondary sex characteristics. Puberty blockers do not result in permanent fertility loss, which only occurs if adolescents opt to continue onto cross-sex hormones a few years later. Instead, delaying puberty allows more time for them to consider their options:

Spack, however, is quick to point out that there is no risk of infertility from the hormone-blocking treatment alone. Infertility only comes when the hormone-blocking treatment is paired with Stage 2, the use of opposite-sex hormones. And so, Spack says, hormone blockers should really be seen simply as a treatment that gives families more time to think about what to do.

“It’s a lot different to be talking to a 14-, 15-, 16-year-old about the implications of this than a 10- to 12-year-old,” he says. “And so it buys you time … without the tremendous fear of their body getting out of control.”

Contrary to descriptions of puberty blockers as “permanent” in their effects on adolescents, this treatment is being used to halt a process that is already taking place and inducing permanent bodily changes: their original puberty. The physical development associated with the initial, “wrong” puberty can be intensely distressing to these youth. Crucially, allowing their initial puberty to take place unhindered would mean that these permanent changes will happen at an earlier age and without any form of consent being given. Adolescents on puberty blockers, however, are given much more time to consider whether transitioning or undergoing their original puberty is the most appropriate path for them, without feeling pressured by impending permanent changes that are out of their control (de Vries & Cohen-Kettenis, 2012):

Puberty suppression has two aims. First and foremost, they offer the adolescent time to smoothly explore his or her gender identity and to find out if a gender reassignment trajectory is really what the youth wants. Moreover, the knowledge that their bodies in this stage will not continue to develop in the undesired direction often results in a vast reduction of the distress they have been suffering from since the onset of puberty.

It makes no sense to object to treatment with puberty blockers on the grounds of permanent effects – this protocol serves to forestall permanent changes by bringing them under the monitoring and control of a precautionary framework designed to meet the needs of adolescents with gender dysphoria. And a wholesale objection to permanent changes would even more strongly condemn choosing not to act: withholding blockers would result in these youth experiencing the permanent changes of puberty at even younger ages.

Weighing benefits and harms of treatment and non-treatment

A narrow focus on the permanence of effects also disregards other ethical considerations that are taken into account when making these choices for gender-dysphoric adolescents. The nature of these permanent effects, and their accompanying benefits and harms, must be weighed as well. Appropriately diagnosed youth are known to be highly likely to benefit from treatment with puberty blockers, and likely to be at risk of negative outcomes without this treatment (Crall & Jackson, 2016):

The best available evidence, along with decades of clinical experience, indicates that effective hormone therapy has a positive effect on psychological and quality of life outcomes in transgender people. . . .

The causal pathway to higher rates of mental illness in transgender youth is illuminated by a recent study, which found that socially transitioned transgender children who are supported in their gender identity have developmentally normal levels of depression and only minimal elevations in anxiety compared to other children their age. This finding suggests that psychopathology within this group is a product of poor social acceptance rather than an intrinsic part of transgender identity. Pubertal suppression and hormone therapy are the chief tools physicians have at their disposal for minimizing a transgender patient’s risk of suffering adverse mental health outcomes.

The health consequences of not blocking puberty, thus leaving their gender dysphoria untreated, can be wide-ranging (Radix & Silva, 2014):

For these transgender adolescents, forcing them to undergo puberty in their natal sex can result in severe dysphoria, depression, suicidality, and self-harming behaviors.

Researchers and clinicians, including those who first introduced puberty blockers as a treatment for trans youth (Cohen-Kettenis, Delemarre-van de Waal, & Gooren, 2008), have noted that withholding treatment is not a neutral or “default” choice:

Finally, in judging the desirability of hormonal pubertal suppression as a first but reversible phase in the sex reassignment procedure, one should not only take consequences of the intervention into account. Rather, one should also consider the consequences of nontreatment. Nonintervention is not a neutral option, but has clear negative lifelong consequences for the quality of life of those individuals who had to wait for treatment until after puberty.

Likewise, bioethicists have stated that evaluating the ethics of this treatment requires recognizing the likely results of not receiving treatment (Giordano, 2008):

Whether or not the administration of puberty suppressant drugs is ethical depends not only on the net balance of clinical risks and benefits of treatment, but also on what is likely to happen to the child if s/he is not treated at the early stages of puberty. On balance, healthcare providers should include future physical risks (invasiveness of future surgery), and the psychological and relational/social risks (disgust for the self; social integration; risk of suicide). Healthcare providers are ethically (and to some extent legally) responsible for what is likely to happen to the applicant as a consequence of the fact that treatment has been withheld.

The analogy to the permanence of tattooing fails to capture the essential characteristics of the situation facing trans youth. Having a condition which requires treatment is not a matter of choice – while “we don’t let kids get tattoos” is clear in its meaning, saying “we don’t let kids have conditions in need of medical treatment” would be nonsensical. Gender dysphoria isn’t something which youth can simply decide not to have, nor can those with dysphoria opt out of the negative health impacts of not receiving puberty blockers. The comparison of a health condition to the choice to get a tattoo is flippant and dismissive of these real harms – harms which can be successfully mitigated using treatment with blockers. If tattoos were shown to provide the same degree of medical benefit to appropriately diagnosed youth, the ethics of tattooing children would be seen in a rather different light.

Medical professionals guide the decision-making process

These arguments also falsely depict the decision of whether to administer puberty blockers as being made solely by the child. In practice, a team of specialists evaluates each case extensively before making any decisions about treatment. The Netherlands clinic describes an assessment process involving the adolescent, their parents, psychologists, and psychiatrists (Delemarre-van de Waal & Cohen-Kettenis, 2006):

In the first diagnostic phase, information must be obtained from both the adolescent and the parents on various aspects of general and psychosexual development of the adolescent, the adolescent’s current functioning and functioning of the family. Standardized psychological assessment is a part of the procedure. The patient is always seen by two members of the gender team. If a child and adolescent psychologist makes the diagnosis, the child is also seen by a child and adolescent psychiatrist and vice versa. . . .

Since the diagnostic procedure is lengthy, there is ample time for patient, the family and the psychologist or psychiatrist to make the final decision.

The GeMS clinic for trans youth at Boston Children’s Hospital also includes parents, psychologists, psychiatrists, social workers, and endocrinologists as part of a comprehensive diagnostic process (Spack et al., 2012):

Beginning in 2009, individuals seeking care were triaged via telephone by the social worker, who obtained information about basic demographics, psychosocial functioning, and existing mental health supports. A letter sent to each referring therapist asked for information about their background, philosophy, and experience with GID; their patient’s history and supports; and mental health concerns. . . .

Patients considered eligible for medical intervention (GnRH analogs and/or cross-sex hormones), first met with a psychologist, along with their parents, for a gender-identity–focused, structured, comprehensive clinical interview and psychometric testing. The psychological protocol was adapted from the Adolescent Gender Identity Research network to assess the degree of gender dysphoria, coexisting psychiatric conditions, and psychosocial stability. They next saw the pediatric endocrinologist, who took a full history, performed a physical exam, and ordered relevant blood tests and bone age films.

. . . In 2009, the GeMS program expanded its original staff composition to include social work and psychiatric services.

Far from being a spur-of-the-moment choice made by a child and subject to no further review, numerous professionals who specialize in working with trans youth are involved long before any decision to start treatment is made. Children are not making this choice – adults are. These clinicians are the ones who must give the go-ahead to begin puberty blockers.

Youth can offer informed consent to puberty blockers

Moreover, doctors working with trans youth do recognize the importance of ensuring that these patients offer informed consent to treatment with blockers, with an appropriate understanding of what this choice entails. While the ability to offer informed consent can depend on an individual child’s maturity level, clinicians consider most youth to be capable of making this decision. Researchers at the Netherlands clinic describe this consent as an ongoing process throughout evaluation and treatment (Cohen-Kettenis et al., 2008):

Naturally, in order to give valid consent, the applicant must receive as complete as possible information about treatment, and has to be informed about the unknown risks of each stage of therapy. The person will then consider and weigh the unknown risks of treatment and the potential benefits on one side, and all the known psychological and physical effects of nontreatment on the other. It will be clear that in the case of a complex treatment such as SR [sex reassignment], informed consent is not given at a single point in time. Rather, it is a process during which the adolescent is progressively more able to understand what the decision is all about.

Version 7 of the WPATH Standards of Care states that obtaining informed consent – potentially requiring the involvement of parents or guardians – is necessary in order for youth to receive blockers (Coleman et al., 2011):

In order for adolescents to receive puberty suppressing hormones, the following minimum criteria must be met: . . . The adolescent has given informed consent and, particularly when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process.

Bioethicists also consider trans youth to be able to offer consent after being fully informed about the likely outcomes of treatment and non-treatment (Giordano, 2008):

In order to give valid consent, applicants need to receive honest information about known and potential risks and benefits of the treatment. In the balance, the applicant (often with the help of his/her parents) will weigh the known and potential risks and benefits of treatment with the known psychological and physical effects of non-treatment. There is no reason to regard consent thus obtained as invalid.

It is not necessarily unethical to treat children within an experimental monitored programme. Indeed, it might be unethical to deny what is for many the only possible cure.

If this cure was likely to cause significant harm to the child, it would be appropriate to question its legitimacy even in the face of the child’s competence and informed consent, but research shows that SP [suspension of puberty] appears to have no hideous or non-controllable side effects.

Further, the issue of fertility loss due to use of puberty blockers is explicitly acknowledged by doctors and counselors. The Endocrine Society’s guidelines for treatment of transgender patients recommend that professionals and other adults assist adolescents in understanding the future implications of this treatment (Hembree et al., 2009):

Persons considering hormone use for sex reassignment need adequate information about sex reassignment in general and about fertility effects of hormone treatment in particular to make an informed and balanced decision about this treatment. Because early adolescents may not feel qualified to make decisions about fertility and may not fully understand the potential effects of hormones, consent and protocol education should include parents, the referring MHP(s) [mental health providers], and other members of the adolescent’s support group.

In their Guidelines for Psychological Practice With Transgender and Gender Nonconforming People, the American Psychological Association (2015) advises psychologists to take an active role in ensuring that trans adolescents grasp the impact of blockers on their fertility:

When TGNC [transgender and gender nonconforming] people consider beginning hormone therapy, psychologists may engage them in a conversation about the possibly permanent effects on fertility to better prepare TGNC people to make a fully informed decision. This may be of special importance with TGNC adolescents and young adults who often feel that family planning or loss of fertility is not a significant concern in their current daily lives, and therefore disregard the long-term reproductive implications of hormone therapy or surgery. . . . Psychologists may play a critical role in educating TGNC adolescents and young adults and their parents about the long-term effects of medical interventions on fertility and assist them in offering informed consent prior to pursuing such interventions.

Pediatric endocrinologists working with trans adolescents have also noted that youth and their families generally consider the loss of fertility to be less important than the benefits of treatment (Shumer, Nokoff, & Spack, 2016):

It is important that families receive counseling regarding the fertility effects of GnRH agonists and cross-sex hormones. A child who starts on GnRH agonist therapy at SMR [sexual maturity rating] stage 2 and continues on the medication as cross-sex hormones are introduced later in adolescence will never have spermatogenesis or menarche, and will not have the opportunity to bank gametes using cryopreservation. Yet for many patients and families, after appropriate informed consent, the benefits of pubertal suppression still outweigh the risks.

Popular arguments depicting youth transition as an inappropriately permanent choice, made solely by unready children and adolescents and irresponsibly enabled by adults, offer a highly distorted portrayal of the medical realities facing transgender kids. These youth aren’t given the option of having gender dysphoria or not – only the option of treating their gender dysphoria or not. Numerous studies in specialized clinics for trans kids have shown that those who receive treatment with puberty blockers experience measurable benefits to their mental health, functioning, and quality of life. Conversely, gender-dysphoric youth who are denied this treatment are likely to suffer a variety of negative health outcomes including depression, self-harm, and suicidality.

Trans kids are confronted with these permanent consequences regardless of their readiness for this, and this is why they receive in-depth consultation with specialists throughout the process of diagnosis and treatment. Puberty-blocking treatment for trans youth is far from an irresponsible and impulsive decision. It is the most responsible and deliberate approach to weighing all of these serious concerns and reaching a suitable conclusion for each child based on their personal needs and the long-term impact on their life. ■

References

• American Psychological Association. (2015). Guidelines for Psychological Practice With Transgender and Gender Nonconforming People. American Psychologist, 70(9), 832–864.
• Cohen-Kettenis, P. T., Delemarre-van de Waal, H. A., & Gooren, L. J. G. (2008). The treatment of adolescent transsexuals: changing insights. Journal of Sexual Medicine, 5(8), 1892–1897.
• Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., . . . Zucker, K. (2011). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism, 13(4), 165–232.
• Crall, C. S., & Jackson, R. K. (2016). Should psychiatrists prescribe gender-affirming hormone therapy to transgender adolescents? AMA Journal of Ethics, 18(11), 1086–1094.
• Delemarre-van de Waal, H. A., & Cohen-Kettenis, P. T. (2006). Clinical management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects. European Journal of Endocrinology, 155, S131–S137.
• de Vries, A. L. C., & Cohen-Kettenis, P. T. (2012). Clinical management of gender dysphoria in children and adolescents: the Dutch approach. Journal of Homosexuality, 59(3), 301–320.
• Giordano, S. (2008). Lives in a chiaroscuro. Should we suspend the puberty of children with gender identity disorder? Journal of Medical Ethics, 34(8), 580–584.
• Hembree, W. C., Cohen-Kettenis, P., Delemarre-van de Waal, H. A., Gooren, L. J., Meyer, W. J. III, Spack, N. P., . . . Montori, V. M. (2009). Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology & Metabolism, 94(9), 3132–3154.
• Radix, A., & Silva, M. (2014). Beyond the guidelines: challenges, controversies, and unanswered questions. Pediatric Annals, 43(6), e145–e150.
• Shumer, D. E., Nokoff, N. J., & Spack, N. P. (2016). Advances in the care of transgender children and adolescents. Advances in Pediatrics, 63(1), 79–102.
• Shumer, D. E., & Spack, N. P. (2013). Current management of gender identity disorder in childhood and adolescence: guidelines, barriers and areas of controversy. Current Opinion in Endocrinology, Diabetes & Obesity, 20(1), 69–73.
• Spack, N. P., Edwards-Leeper, L., Feldman, H. A., Leibowitz, S., Mandel, F., Diamond, D. A., & Vance, S. R. (2012). Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics, 129(3), 418–425.