Sarah Jorgensen and Céline Masson argue that delaying decisions about medical transition until a child has had the chance to grow and mature into an autonomous adult is most consistent with the open future principle.

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In early April, the long-anticipated Cass Review of England’s gender services for children and young people was published. The review, led by Dr. Hillary Cass, former president of the Royal Society of Pediatrics and Child Health, was informed by eight systematic evidence reviews, as well as the experiences of a wide range of stakeholders, including young people with gender dysphoria, their parents, transgender adults, people who had detransitioned, and clinicians. The review found that the rationale for early puberty suppression remains unclear and that evidence supporting the use of puberty blockers and hormonal therapies in children and adolescents was “built on shaky foundations”.

In a recent article, we examine the clinical and ethical implications of puberty blockers for children with gender dysphoria through the lens of “the child’s right to an open future”. Introduced by philosopher Joel Feinberg more than 40 years ago, the open future principle refers to rights that children do not have the capacity to exercise as minors, but that must be protected so they can exercise them in the future as autonomous adults.

Photo Credit: Claire CJS/flickr. Image Description: A person preparing a Leuprolide Acetate injection.

Whereas Feinberg recognized that a child’s future interests are not necessarily best served by protecting their “budding right to self-determination,” the prescription of puberty blockers as part of gender-affirming care centers the child’s immediate desires and self-fulfillment. However, this commitment to respecting a child’s present autonomy overlooks important aspects of child and adolescent development. Evidence from animal and human studies suggest that difficulties controlling behavior and emotions during adolescence stem from a biologically driven disjunction between novelty and sensation seeking on one hand, both of which increase dramatically at puberty, and the development of self-regulatory competence, on the other, which does not fully mature until early adulthood. Peer pressure, impulsivity, and risk-seeking can often impair an adolescent’s ability to make decisions that promote their long-term well-being. Reflecting adolescents’ tendency to prioritize immediate rewards even when this can mean later loss or negative repercussions, interviews by Dutch researchers reveal that uncertainty about long-term negative effects of puberty suppression would not stop adolescents pursuing puberty suppression, with many believing that the chance for relief from current unhappiness was far more important than possible negative long-term consequences of these drugs.

Several studies from the Netherlands have demonstrated that clinicians who endorse the gender affirming care model wrestle with uncertainty about a child’s competence to consent to puberty suppression. Many clinicians interviewed for these studies were doubtful that children could truly understand potential long-term health and psychosocial consequences of puberty suppression and they were especially troubled by the possibility of foreclosing fertility options knowing a child’s desire to have biological children could change as they mature.

Although it has been argued that allowing endogenous puberty to proceed unimpeded could foreclose a child’s right to achieve their “gender embodiment goals,” this framing rests on assumptions that are not supported by evidence. Puberty suppression is not a reversible, standalone intervention, but instead, triggers a cascade of increasingly invasive medical interventions. Rather than buying time for children to explore their feelings about gender and weigh risks and benefits of various treatment options, as proponents of puberty suppression have often claimed, multiple studies demonstrate nearly all children who undergo puberty suppression proceed to cross-sex hormones. In one study, children who underwent puberty suppression stated that they did not consider it to be a way to buy time to decide about further steps; they were already certain that they wanted cross-sex hormones and, for some, surgery when starting puberty blockers. Dutch gender clinicians have likened the situation to a train already on its course to a predetermined destination.

Application of the open future principle to puberty suppression for children with gender dysphoria requires balancing potential short- and long-term risks and benefits for all treatment options and considering how each alternative could increase or decrease the range of opportunities that will be available to the child in the future. However, multiple systematic reviews that have concluded there is great uncertainty about the balance of benefits and risks associated with puberty suppression. Moreover, the natural trajectory of gender dysphoria in the current cohort of predominantly adolescent females with complex psychiatric and neurodevelopmental conditions is still uncertain and therapeutic endpoints are in flux. Critically, how does achieving present “gender embodiment goals” weigh against future goals as well as potential harms of puberty blockers which may include lifelong medicalization, altered brain development, diminished bone strength, and the loss of the ability to have biological children or experience sexual pleasure?

Several European countries, in addition to England, have adopted a more cautious approach after conducting systematic reviews of the evidence and finding them to be insufficient to support treatment recommendations. By contrast, the US and Canada continue to endorse the gender affirming care model, and present puberty suppression as a “tragic compromise,” necessitated by the intractable distress associated with experiencing the “wrong” puberty, together with the risk of suicide if access to these drugs is denied or delayed. However, suicide in children with gender dysphoria is, thankfully, extremely rare and may be driven by prevalent psychiatric comorbidities rather than gender dysphoria per se. Moreover, there is no compelling evidence that puberty blockers reduce the risk of suicide. Suggesting otherwise could cause the small number of children who truly are at high risk of suicide to forgo evidence-based suicide prevention interventions.

Treatment pathways that delay decisions about medical transition until the child has had the chance to grow and mature into an autonomous adult would be most consistent with the open future principle. As Feinberg stated, a child’s long-term interests, “cannot be established by determining [their] present desires.” To believe otherwise ignores decades of empirical evidence in child and adolescent developmental psychology.

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Sarah Jorgensen is a postdoctoral fellow at Dalla Lana School of Public Health and Ottawa Hospital Research Institute.

Céline Masson is a psychoanalyst at Université de Picardie Jules-Verne.